Title Page
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Employers Details:
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Employer's Name:
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Number of Employees:
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Nature of Business (Main Occupation):
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Workplace Address:
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Main Contact (Name and Telephone number):
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Email Address:
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Health and Safety Contact:
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Work area assessed (i.e. full site, part site):
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Enforcement action (Prosecutions, notices):
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For Office Use Only
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Type of Assessment:
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Date Initial Assessment Completed:
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Date Re-Assessment Completed:
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Assessment Outcome:
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Recommendation:
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Risk Level:
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Designated Document Owner:
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Date Actions Completed:
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Date of next Assessment:
Q 1-5
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1 - Health and Safety Management
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A - Is there a clear commitment to health, safety & welfare (poster displayed and/or written policy statement-mandatory when 5 or more employees)?
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Evidence/ Comments
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B - How are the commitment, responsibilities and arrangements for health & safety communicated to employees?
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C - Is there current:
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-Employer's Liability Insurance
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Employers Liability Insurance:
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Insurer's Name:
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Policy Number:
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Expiry Date:
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-Public Liability Insurance
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Public Liability Insurance:
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Insurer's Name:
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Policy Number:
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Expiry Date:
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Other insurance appropriate to the business undertaking?
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2 - Safe and Healthy Working Environment
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B - Is the working environment (temperature, lighting, space, ventilation, nise) an appropriate safe and healthy one?
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Evidence/ Comments
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A - Are premises (structure, fabric, fixtures and fittings) safe and healthy (suitable, maintained and kept clean)?
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Evidence/ Comments
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C - Are welfare facilities (toilets, washing, drinking, eating, changing) provided as appropriate and maintained?
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Evidence/ Comments
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D - Does the employer display the necessary signs and notices around the workplace?
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Evidence/ Comments
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3 - Fire and Emergencies
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B - Are there appropriate means of fighting fire in place?
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Evidence/ Comments
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A - Does the company have emergency evacuation procedures and what are they?
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Evidence/ Comments
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C - Are effective means of escape in place including unobstructed routes and exits?
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Evidence/ Comments
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4 - Accidents, Incidents and First Aid
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A - Does the company have accident and incident procedures? and what are they in relation to:<br> - First Aid provision<br> - Responsible person<br> - Reporting procedure
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Evidence/ Comments
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5 - Work Equipment and Machinery
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B - Is equipment adequately maintained?
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Evidence/ Comments
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A - Is correct machinery and equipment (mechanical and/or electrical) provided to the appropriate standards?
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Evidence/ Comments
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C - Are guards and control measures in place as determined through risk assessment?
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Evidence/ Comments
Q 6-8
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6 - Risk Assessment and Control
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A - Have risk assessments been carried out, control measures identified and put in to place?
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Evidence/ Comments
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B - Do they take into account young persons, including giving consideration to their age, inexperience, immaturity and lack of awareness of risks?
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Evidence/ Comments
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C - Have the significant findings and details of any groups identified as being especially at risk been recorded (mandatory where 5 or more employees)?
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Evidence/ Comments
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7 - Personal Protective Equipment and Clothing
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A - Is PPE/C provided, free of charge, to employees as determined through risk assessment?
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Evidence/ Comments
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B - Is training and information on the safe use of PPE/C provided to employees?
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Evidence/ Comments
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C - Is the proper use and storage of PPE/C enforced?
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Evidence/ Comments
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D - Is PPE/C maintained and replaced?
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Evidence/ Comments
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8 - Information, Supervision, Instruction and Training
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A - Is health and safety information, instruction and training given to employees at induction and on an ongoing basis?
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Evidence/ Comments
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B - Is the health and safety information, instruction and training recorded?
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Evidence/ Comments
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C - Are employees provided with adequate competent supervision? If applicable - who is responsible for supervising the learner on the programme of study?
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Evidence/ Comments
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Please sign to agree that this is an accurate record of the assessment conducted.
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The Employer (or their representative)
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Signed:
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Print Name:
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Job Title:
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Date:
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Telford College of Arts and Technology (Person completing the Health and Safety Checklist)
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Signed:
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Print Name:
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Job Title:
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Date:
Action Plan
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Action Plan - reference to numbering system in assessment record above:
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Ref:
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Action Required:
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By who:
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Target Date:
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Completion Date:
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Action Required:
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By who:
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Target Date:
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Completion Date:
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Action Required:
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Completion Date:
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Action Required:
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Completion Date:
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Action Required:
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Completion Date:
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Action Required:
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Completion Date:
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Ref:
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Action Required:
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By who:
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Target Date:
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Completion Date:
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Action plan agreed by
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Name:
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Signature:
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Date:
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Action plan prepared by
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Name:
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Signature:
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Date:
