editable health and safety forms

7/27/2019 Editable Health and Safety Forms

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Contents

1. Examples of risk assessment forms

a. General Risk assessment form

b. Risk assessment report form example

c. Contractors’ risk assessment example for confined spaces NIB

d. Contractors’ risk assessment example for work on fragile roofs NIB

e. Machinery risk assessment example NIB

2. Job safety analysis form

3. Essential elements of a permit-to-work form

4. An example of a set of COSHH assessment forms

a. COSHH 1 - DETAILS OF SUBSTANCES USED OR STORED

b. COSHH 2 - ASSESSMENT OF A SUBSTANCE

5. Example of a workstation self-assessment checklist (DSE)

6. Example of a noise assessment record form

7. Example of a workplace inspection report form

8. Workplace inspection checklist

9. Accident/incident report form

10. Manual handling of loads assessment checklist

11. Manual handling risk assessment

12. Example fire safety maintenance checklist NIB

13. Example fire risk assessment record of significant findings

14. Construction inspection report form

1



1 – (a) General Risk assessment form

General Health and Safety Risk AssessmentExample 1

No

Firm/Company

Department

ContactName

Nature of Business

TelephoneNo

Principal Hazards

1

2

3

4

5

Persons at Risk

Main Legal Requirements1

2

3

4

5

Significant Risks Consequences1

2

3

4

5

Existing Control Measures1

2

3

4

5

Residual Risk, i.e. after controls are in place.

Severity Likelihood Residualrisk

Information relevant HSE and trade publications

Comments from Line Manager Comments from Risk Assessor

Signed Date Signed Date

Review Date

2



(b) Risk Assessment Report Form

Name of Company: Date of Assessment:Name of Assessor: Date of Review:

HazardsPersonsaffected

RisksInitial Risk

LevelExisting Controls Additional Controls

Action bywhom?

Action bywhen?

Done

3



(c) Contractors’ risk assessment example for confined spaces

INITIAL RISK ASSESSMENT Work in Confined SpacesSIGNIFICANT HAZARDS Low Medium High

1. Poisoning from toxic gases

2. Asphyxiation - lack of oxygen

3. Explosion

4. Fire

5. Excessive heat 6. Drowning

7.

8.

ACTION ALREADY TAKEN TO REDUCE THE RISKS:

Compliance with:

H S E Guidance Note - Entry into Confined SpacesLocal Authority/client safety standards, e.g. on sewer entry.Entry into Confined Spaces Regulations 1997The Construction (Design and Management) Regulations 2007Dangerous Substances and Explosive Atmospheres Regulations.

Planning:

Eliminate need for entry or use of hazardous materials by selection of alternative methods of work or materials. Assessment of ventilation available and possible local exhaust ventilation requirements, potential presence of hazardous gases/atmosphere, process by-products, need for improved hygiene/welfare facility.

Physical:

Documented entry system will apply, with a Permit to Work. Adequate ventilation will be present or arranged.Detection equipment will be present before entry to check on levels of oxygen and presence of toxic or explosivesubstances. The area will be tested before entry and continually during the presence of persons in the confinedspace. Breathing apparatus or airlines will be provided if local ventilation is not possible. Where no breathingapparatus is assessed as being required, emergency BA and rescue harnesses will be provided. Rescueequipment including lifting equipment, resuscitation facilities safety lines and harnesses will be provided. Acommunication system with those in confined space will be established. Air will not be sweetened with pureoxygen. Precautions for safe use of any plant or heavier-than-air gases in the confined space must be establishedbefore entry. Necessary P PE and hygiene facilities will be provided for those entering sewers.

Managerial/Supervisory:

The management role is to decide on nature of the confined space and to put a safe system into operation,including checking the above. Flood potential and isolations must be checked.

Training:

Full training required for all entering and managing confined spaces. Rescue surface party to be trained, includingfirst aid and operation of testing equipment. All operatives must be certified as trained and supervisory staff trainedto the same standard.

Risk Re-Assessment Date............................. Site Manager’s Comments:

4



(d) Contractors’ risk assessment example for Work on Fragile Roofs –example 4

INITIAL RISK ASSESSMENT Work on Fragile RoofsSIGNIFICANT HAZARDS Low Medium High

1. Falls of persons through materials √

2. Access across fragile material √3.

4.

5.

6.

7.

8.

ACTION ALREADY TAKEN TO REDUCE THE RISKS:

Compliance with:

Lifting Operations & Lifting Equipment Regulations. (L O L E R)

Provision and Use of Work Equipment Regulations. (P U W E R)Work at Height Regulations 2005H S E Guidance Booklet HS (G) 33 - Safety in Roof workConstruction (Design and Management) Regulations 2007.

Planning:

Fragile materials will be identified before work begins. In each case, an assessment of risk will be made to providea safe system of work taking account the work to be done, access/egress requirements and protection of the areabeneath the work area.

Physical:

Suitable means of access will be provided, such as roof ladder, crawling boards, scaffolding, and staging. Whereaccess is possible alongside fragile materials such as roof lights, covers will be provided or the fragile material will

be fenced off, catch nets will be provided as appropriate. Barriers and signs will be provided so as to isolate thearea below fragile materials while work is in progress. No person is permitted to walk upon suspected fragilematerials for any purpose, including access and surveying.

Managerial/Supervisory:

The role of management is to define a safe work method prior to commencement of work, and to arrange for provision of suitable access equipment and trained personnel as required by the safe system devised. Managersmust check risk assessments and method statements supplied by subcontractors and others, including the self-employed, to ensure that the proposed work method is safe.

Training:

All operatives must be given specific instructions on the system of work to be used in each case. Selection may berequired of operatives who have experience of the work and are physically fit.

Risk Re-Assessment Date............................. Site Manager’s Comments:

5



(e) Machinery Risk Assessment - example 5

Machine No Model Manufacturer Risk Assessment no

Model No Other Department ID

Hazards

Hazard Yes No Hazard Yes

No

Trapping Electrocution

Impact Pressure

Contact Hot/Cold

Entanglement Fire

Ejection Other

Who might be

harmed?

Operatives Cleaners Maintenance Visitors Others

Guarding

Fixed Guards Interlocked MovableGuards

Adjustableguards

Fixed Distanceguard

AdequateEnclosure of drives and motors

Fitted to machine Fitted to machine Fitted to machine

Closed to run Readilyadjustable

Securely fixed

Securely fixed inposition

Design OK withpositive switches& robust

PreventEjection

Prevents access todanger zone

Tool required to

remove

Safe to open Maintained OK Tool to remove

Maintained OK Maintained OK

Controls /Warnings/ Instructions /Training

Controls Instruction/ Training

Area

Clearlyidentified

Shroudedstart

Warningsigns

Lighting OK

Function clear Warningdevice

Signs clear Stability OK

Easy to use Isolatornearby

Safety sheet OK

Ventilation OK

Emergencystop

Isolatorlockable

SOPavailable

LEV needed

Machine stopsok

Permitrequired

Training OK Accessoperator s

Safe at stop Seatingneeded

Accessmaintenance

Action Required

6



SEVERITY FREQUENCY

RISIDUAL RISK (S x F)

2- Job safety analysis form

JOB SAFETY ANALYSISJob Date

Department Carried out by

Description of job

Legal requirements and guidance

Task steps Hazards Consequence/Likelihood

Severity RiskL X S

Controls

Safe system of work

Job Instruction

Training requirements

Review date

7



3 - Essential elements of a permit-to-work form

1 Permit Title 2 Permit No

3 Job Title

4 Plant identification

5 Description of Work

6 Hazard Identification

7 Precautions necessary 7 Signatures

8 Protective Equipment

9 Authorization

10 Acceptance

11 Extension/Shift handover

12 Hand back

12 Cancellation

8



4 - An example of a set of COSHH assessment forms

COSHH 1 - DETAILS OF SUBSTANCES USED OR STORED

Name of Manager: …………………………………………………………………………………

Name of Department/Area;………………………………………………………………………..

SUBSTANCE DETAILS1. Information from the label

Trade name:……………………………………………………………………………………

Manufacturer's name:………………………………………………………………………..

Names of any chemical constituents listed:……………………………………………….

………………………………………………………………………………………………….

Hazard marking - whether corrosive, irritant, harmful, toxic, very toxic………………….…………………………………………………………………………………………………..

RISKS Phrases noted on label (e.g. Harmful in contact with skin)

………………………………………….....................................................................................

...............................................................................................................................................

Safety Phrases noted on labels (e.g. avoid contact with skin)

…………………………………………………………………………………………………........

...............................................................................................................................................

PRECAUTIONS noted on label (e.g. Use in well ventilated area)………………………....……………………………………………………………………………………………....………………………………………………………………………………………………….

………………………………………………………………………………………………….

2. Have you got a Health & Safety Data Sheet for this product? YES/NO

DETAILS OF USE

3. What it is used for?.............................................................................................................

……………………………………………………………………………………………………

4. By whom?............................................................................................................................

5. How often?..........................................................................................................................

6. Where?................................................................................................................................

7. What CONTROL measures (precautions) are used? (E.g. local ventilation, goggles,

respirator, protective gloves. etc.)……………………………………………………………..

………………………………………………………………………………………….....

…………………………………………………………………………………………….

…………………………………………………………………………………….……...

8. Is it ABSOLUTELY ESSENTIAL to keep/use this substance? YES/NO

9. Can it be DISPOSED OF NOW? YES/NO

9



COSHH 2 - ASSESSMENT OF A SUBSTANCE

1. Name of substance:………………………………………………………………………….........

2. The process or description of job where the substance is used………………………….......

……………………………………………………………………………………………………........

3. Location of the process where substance is used………………………………………….....

4. Health & safety information on substance:

a) Hazards to health:…………………………………………………………………………........

……………………………………………………………………………………………………........ ......

……………….…………………………………………………………………………………….

b) Precautions required:………….…………………………………………………………….....

…….………….…………………………………………………………………………………….......

………….……………………………………………………………………………………………....…….………….……………………………………………………………………………………......

…….………….……………………………………………………………………………………......

5. Number of persons exposed:………………………………………………………………….....

6. Frequency and duration of exposure:…………………………………………………………...

7. Control measures that are in use:…………………………………………………………….....

………………………………………………………………………………………………………....

………………………………………………………………………………………………………....

………………………………………………………………………………………………………....

………………………………………………………………………………………………………....

8. The assessment, an evaluation of the risks to health:………………………………………..

………………………………………………………………………………………………………....

………………………………………………………………………………………………………....

………………………………………………………………………………………………………....

………………………………………………………………………………………………………...

9. Details of steps to be taken to reduce the exposure:………………………………………...

………………………………………………………………………………………………………...

………………………………………………………………………………………………………...

………………………………………………………………………………………………………...

………………………………………………………………………………………………………...

10. Action to be taken by (name) :…………………………………………(Date):……………....

11. Date of next assessment/review: .....................

12. Name and position of person making this assessment: ...................................................

13. Date of assessment: ................................



5 - Example of a Workstation Self AssessmentChecklist

Name Department: Date:

The completion of this checklist will enable you to carry out a self-assessment of your own workstation. Your views are essential in order to enable us to achieve our objective of ensuring your comfort and safety atwork. Please circle the answer that best describes your opinion, for each of the questions listed. The formshould be returned to…………………………as soon as it has been completed.

Environment

1. Lighting

Describe the lighting at your usual workstation.

About right Too bright Too dark

Do you get distracting reflections on your screen?

Never Sometimes Constantly

What control do you have over local lighting?

Full control Some control No control

2. Temperature and humidity

At your workstation, is it usually:

Comfortable Too warm Too cold?

Is the air around your workstation:

Comfortable Too dry?

3. Noise

Are you distracted by noise from work equipment?

Never Occasionally Constantly

4. Space

Describe the amount of space around your workstation.

Adequate Inadequate

Furniture

5. Chair Can you adjust the height of the seat?

Yes / NoCan you adjust the height and angle of the backrest?Yes / No

Is the chair stable?Yes / No

Does it allow movement?Yes / No



Record (continued)

Display Screen Equipment (continued)

Keyboard (continued)

Can you raise and lower the keyboard height?Yes / No

Can you easily see the symbols on the keys?Yes / No

Is there enough space to rest your hands in front of the keyboard?Yes / No

11. Software

Do you understand how to use the software?Yes / No

12. Training

Have you been trained in the use of your workstation?Yes / No

Have you been trained in the use of software?Yes / No

If you were to have a problem relating to display screen work, would you know thecorrect procedures to follow?

Yes / No

Do you understand the arrangements for eye and eyesight tests?Yes / No

Any other comments?

13



6 - Example of a Noise Assessment Record Form

Name of Department: Date of Survey:Lower Exposure Action Level:

80 dBA daily or weeklyUpper Action Level:85 dBA daily or weekly

Peak Pressure:135 dB(C)/137dB(C)

WorkplaceNumber of

PersonsExposed

NoiseLevel(Leq)dB(A)

DailyExposure

Period

LEP'ddB(A)

Peak PressuredB(C)

Comments

General Comments:

Instrument Used: Date of Last Calibration:

Signature: Position: Date:

14



7 - Example of a Workplace Inspection Report

Form

Workplace Inspection Cover Sheet

Name of Company/Organization

Work area covered bythis Inspection

Activity carried out inwork place

Person carrying outinspection(PLEASE PRINT)

Date of Inspection

(See Appendix 7.3 Inspection Checklist and Appendix 5.1 for hazard checklist)

ObservationsList hazards, unsafe practices and goodpractices

Priority/risk(H,M,L)

Actions to be taken (if any)List all immediate andlonger-term actionsrequired

Time ScaleImmediate1 week etc

15



8 - Workplace Inspection Checklist

PREMISES

1 Work at Height Ladders/step Right equipment for the job?

ladders Level base?

Correct angle?

Secured at top and bottom?

Equipment in good condition?

Regularly inspected

Working Suitable for the task

platforms/ Properly erected?

Good access?

temporary Maintained and inspectedscaffolds

Use of mobile Suitable for task?

elevating workplatforms

Operators properly trained?Properly maintained

2 Access Access ways Adequate for people, machinery and work in

progress?

Unobstructed?

Properly marked?Stairs in good condition?Handrails provided?

Housekeeping Tidy, clean, well organized?

Flooring Even and in good condition?

WorkingEnvironment

Non-slippery?

Comfort /health Crowded?Too hot/cold? Ventilation?Humidity? Dusty? Lighting?

Cleaning Slip risk controlled?Hygienic conditions

Noise Normal conversation possible?Noise assessment needed/not needed?

Noise areas designated?Ergonomics Tasks require uncomfortable postures or

actions?

Frequent repetitive actions accompanying

muscular strain?

Visual display Workstation assessments needed/not needed

units Chairs adjustable/comfortable/maintained

properly?

Cables properly controlled?Lighting OK? No glare?

16



4 Welfare Toilets /Washing Washing and toilet facilities satisfactory?Kept clean, with soap and towels/ Adequate changing facilities

Eating facilities Clean and adequate/Means of heating food?

Rest roomFor pregnant or nursing mothersKept clean?

First aid

Suitably placed and provisioned? Appointed person?Trained first aider?Correct signs and notices?Eye wash bottles as necessary?

5 Services Electricalequipment

Portable equipment tested?Leads tidy not damaged?Fixed installation inspected

Gas Equipment serviced annually?

Water Hot and cold water provided?Drinking water provided?

6 Fire precautions Fireextinguishers

In place? Full? Correct type?Maintenance contract?

Fire instructions Posted up?Not defaced or damaged?

Fire alarms Fitted and tested regularly?

Means of Adequate for the numbers involved?

escape/ Fire Unobstructed?

exits Easily opened?

Properly signed?

Means of Adequate for the numbers involved?escape/ Fire Unobstructed?

exits Easily opened?

Properly signed?

17



PLANT AND SUBSTANCES

7 Work Lifting Thoroughly examined?

Equipment equipment Properly maintained?Slings etc properly maintained?

Operators properly trained?

Pressure Written schemes for inspection?

systems Safe working pressure marked?

Properly maintained?

Sharps Safety knives used?

Knives/needles/glass properly

used/disposed of?

Vibration Any vibration problems with hand held

machinery or with whole body from vehicleseats etc?

Tools and Right tool for the job?

equipment In good condition?

Manual Moving excessive weight?

handling Assessments carried out?

Using correct technique?

Could it be eliminated or reduced?

8 Manual &Mechanical

Handling

Mechanical Forklifts and other trucks properly

handling maintained?

Drivers authorized and properly trained?

Passengers only where specifically intended

with suitable seat?

9 Vehicles On site Speeding limits?Following correct route?Properly serviced?Drivers authorized

Road risks Suitable vehicles used?

No use of mobile phones when driving?Properly serviced? Schedules managedproperly?

18



10 Dangerous Flammableliquids andgases

Stored properly?Used properly/minimum quantities inworkplace?Sources of ignition?Correct signs used?

substances

11 Hazardous Chemicals COSHH assessments OK?Exposures adequately controlled?Data sheet information available?Spillage procedure available?Properly stored and separated as necessary?Properly disposed of?

substances

Exhaustventilation

Suitable and sufficient?Properly maintained?

Inspected regularly?

PROCEDURES

12

Riskassessments

Carried out? General and fire?Suitable and sufficient?

13 Safe systemsof

Provided as necessary?Kept up to date/

FollowedWork

14

Permits to work

Used for high risk maintenance?Procedure OK?Properly followed?

15 PersonalProtectiveEquipment

Correct type?Worn correctly?Good condition?

16 Contractors Is their competence checked thoroughly? Are there control rules and procedures? Are they followed?

17 Notices, Signsand Posters

Employers'liabilityinsurance

Notice displayed? In date?

Health andSafety lawposter

Displayed?

Safety Signs Correct type of sign used/Signs in place and maintained?

19



PEOPLE

18 Healthsurveillance

Specific surveillance required by law?Stress or fatigue?

19 People'sbehaviour

Are behaviour audits carried out?Is behaviour considered in the safetyprogramme?

20 Training andsupervision

Suitable and sufficient?Induction training?Refresher training?

21 Appropriateauthorizedperson

Is there a system for authorizing people for certain special tasks like permits to work,dangerous machinery, entry into confinedspaces?

22 Violence Any violence likely in workplace?Is it controlled? Are there policies in place

23 Especially atrisk

categories

Young persons Employed?Special risk assessments?

New or expectantmothers

Employed?Special risk assessments?

20



9 - ACCIDENT/INCIDENT REPORT

INJURED PERSON: ……………………………….Date of Accident: ...../.... /20 Time……….am/pm

POSITION: …………………………………………Place of Accident: …………………………………….

DEPARTMENT: ……………………………………Details of Injury: ……………………………………....

Investigation carried out by: ………………………..……………………………………............................

Position: ……………………….. Estimated Absence: …………………………………..............

Brief details of Accident ( A detailed report together with diagrams, photographs and any witness statementsshould be attached where necessary. Please complete all details requestedoverleaf.)

Immediate Causes Underlying or Root Causes

Conclusions (How can we prevent this kind of incident/accident occurring again?)

Action to be taken: …………………………………Completion Date:.... /....../20

Please ensure that an accident investigation and report is completed and forwarded to Personnelwithin 48 hours of the accident occurring.

Remember that accidents involving major injuries or dangerous occurrences have to be notified

immediately by telephone to the local authority.

Signature of Manager making Report: ……………………………Copies: Personnel Manager Health & Safety Manager

Date:...../...... /20 Payroll Controller

INJURED PERSON: Surname …………………........Forenames ………………..…………............Male/Female

Home address ………………………………………………………............................ Age…………

Consent to share this information with Safety Representatives

Signature of Injured Person............................................Date......./....../.....20...

Employee Agency Temp Contractor Visitor Youth Trainee (Tick one box)

21



Kind of Accident Indicate what kind of accident led to the injury or condition (tick one box)

Contact with moving Injured whilst handling Drowning or Contact with electricity or

machinery or material lifting or asphyxiation an electrical dischargebeing machined 1 5 9 13

Struck by moving Slip, trip or fall on Exposure to or Injured by an animalincluding flying, or same level contact with harmful

falling object 2 6 10 14

Struck by moving Fall from height Exposure to fire Violence

vehicle 3 indicate approx. 7 11 15 Distance of fall………mtrs

Struck againstsomething fixed Trapped by something Exposure to an Other kind of

or stationary 4 collapsing or overturning 8 explosion 12 accident 16

Detail any machinery, chemicals, tools etc. involved

Accident first reported to: Name ……………………………………..

Position & Dept……………………………………………………………………………………………..

First Aid/medical attention by: First Aider Name ……………………Dept ………………………….

Doctor Name …………………...............................................

Medical centre ……………………Hospital……………………….

WITNESSES

Name Position & Dept Statement obtained (yes/no)Attach all statements taken

…………………………… .………………………………………… …………………… yes/no…………………………… .………………………………………… …………………… yes/no…………………………… .………………………………………… …………………… yes/no

…………………………… .………………………………………… …………………… yes/no

For Office use only

If relevant: Date reported to Enforcing Authority a) by telephone ..../….../20b) by internet ..../....../20c) on form F2508 …./…../20

Date reported to Company Insurers …../…../20

Were the Recommendations Effective? Yes/No

If No say what further action should be taken.

22



23



10 - Manual Handling of Loads: Assessment

Manual Handling of Loads: Assessment Checklist

Section A - Preliminary

Task description:

Factors beyond the limits of the guidelines?Is an Assessment needed?(i.e. is there a potential risk of injury, and are thefactors beyond the limits of the guidelines?)

Yes / No

If ‘YES ‘continue. If ‘NO’ the assessment need go no further.

Tasks covered by this assessment(detailed description):

Locations:

People involved:

Date of assessment:

Diagrams and other information:

Section B – See separate sheet for detailed analysis

Section C – Overall assessment of the risk of injury? Low / Medium / High

Section D – Remedial action needed:

Remedial steps that should be taken, in priority order:

a

b

c

d

e

f

g

h

Date by which action should be taken:

Date for reassessment:

Assessor’s name: Signature:

24



11 - Manual Handling Risk Assessment

Manual Handling Risk Assessment Employee checklist

Task Description Employees ID No

Risk Factors

A. Task Characteristics Yes/No Risk Level Current Controls

H M L1. Loads held away from trunk?

2. Twisting?

3. Stooping?

4. Reaching upwards?

5. Extensive vertical movements?

6. Long carrying distances?

7. Strenuous pushing or pulling?

8. Unpredictable movements of loads?9. Repetitive handling operations?

10. Insufficient periods of rest/recovery?

11. High work rate imposed?

B. load characteristics

1. Heavy?

2. Bulky?

3. Difficult to grasp?

4. Unstable/unpredictable?

5. Harmful (sharp/hot)?

C. Work environment characteristics

1. Postural constraints?

2. Floor suitability?

3. Even surface?

4. Thermal/humidity suitability?

5. Lighting suitability?

D. Individual characteristics

1. Unusual capability required?

2. Hazard to those with health problems?

3. Hazard to pregnant workers?

4. Special information/training required?

Any further action needed? Yes/No

Details:

25



Yes No N/A Comments

Do all emergency fastening devices to fire exits(push bars and pads, etc.) work correctly?

Are external routes clear and safe?

Weekly checks continued Fire warning systems

Does testing a manual call point send a signal tothe indicator panel? (Disconnect the link to thereceiving centre or tell them you are doing atest.)

Did the alarm system work correctly whentested?

Did staff and other people hear the fire alarm?

Did any linked fire protection systems operatecorrectly? (e.g. magnetic door holder released,smoke curtains drop)

Do all visual alarms and/or vibrating alarms andpagers (as applicable) work?

Do voice alarm systems work correctly? Wasthe message understood?

Escape lighting

Are charging indicators (if fitted) visible?

Firefighting equipment

Is all equipment in good condition?

Additional items from manufacturer’s

recommendations.Monthly checks

Escape routes

Do all electronic release mechanisms on escapedoors work correctly? Do they ‘fail safe’ in theopen position?

Do all automatic opening doors on escaperoutes ‘fail safe’ in the open position?

Are fire door seals and self-closing devices ingood condition?

Do all roller shutters provided for fire

compartmentation work correctly? Are external escape stairs safe?

Do all internal self-closing fire doors workcorrectly?

Escape lighting

Do all luminaries and exit signs functioncorrectly when tested?

Have all emergency generators been tested?(Normally run for one hour.)

Fire fighting equipment

Is the pressure in ‘stored pressure’ fireextinguishers correct?

27



Yes No N/A Comments

Additional items from manufacturer’srecommendations.

Three-monthly checks

General

Are any emergency water tanks/ponds at their normal capacity?

Are vehicles blocking fire hydrants or access tothem?


Six-monthly checks

General

Has any fire fighting or emergency evacuationlift been tested by a competent person?

Has any sprinkler system been tested by acompetent person?

Have the release and closing mechanisms of any fire-resisting compartment doors andshutters been tested by a competent person?

Fire warning system

Has the system been checked by a competentperson?

Escape lighting

Do all luminaries operate on test for one third of their rated value?


Annual checks

Escape routes

Do all self-closing fire doors fit correctly?

Is escape route compartmentation in goodrepair?

Escape lighting

Do all luminaries operate on test for their fullrated duration?

Has the system been checked by a competentperson?

Fire fighting equipment

Has all fire fighting equipment been checked bya competent person?

Miscellaneous

Has any dry/wet rising fire main been tested by

a competent person?

28



Yes No N/A Comments

Has the smoke and heat ventilation systembeen tested by a competent person?

Miscellaneous continued

Has external access for the fire service beenchecked for ongoing availability?

Have any fire-fighters’ switches been tested?

Has the fire hydrant bypass flow valve controlbeen tested by a competent person?

Are any necessary fire engine direction signs inplace?

29



13- Example Fire risk assessment record of significantfindings

Risk Assessment – Record of significant findings

Fire Risk Assessment – Record of significant findings

Risk assessment for Assessment undertaken by

Company Date

Address Completed by

Signature

Sheet number Floor/area Use

Step 1 - Identify fire hazardsSources of ignition Sources of fuel Sources of oxygen

Step 2 – People at risk

Step 3 – Evaluate, remove, reduce and protect from risk(3.1) Evaluate the riskof the fire occurring

(3.2) Evaluate the risk topeople from a fire startingin the premises

(3.3) Remove and reducethe hazards that maycause a fire

(3.4) Remove and reducethe risks to peoplefrom a fire

Assessment review

Assessment review date Completed by Signature

Review outcome (where substantial changes have occurred a new record sheet should be used)

(1) The risk assessment record of significant findings should refer to other plans, records or other documents as

necessary.(2) The information in this record should assist you to develop an emergency plan; coordinate measures withother ‘responsible persons’ in the building; and to inform and train staff and inform other relevant persons.

30



31



14 - Construction Inspection Report Form

Construction Inspection Report1. Name and address of person for whom inspection was carried out.

2. Site address. 3. Date and time of inspection.

4. Location and description of place of work or work equipment inspected.

5. Matters which give rise to any health and safety risks.

6. Can work be carried out safely? Yes / No

7. If not, name of person informed.

8. Details of any other action taken as a result of matters identified in 5 above.

9. Details of any further action considered necessary.

10. Name and position of person makingthe report.

11. Date and time report handed over.

12. Name and position of personreceiving report.

94I

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