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
No
General Health and Safety Risk Assessment
Example 1
Firm/Company
Department
Contact Name
Nature of Business
Telephone No
Principal Hazards
1
2
3
4
5
Persons at Risk
Main Legal Requirements
1
2
3
4
5
Significant Risks
1
2
3
4
5
Consequences
Existing Control Measures
1
2
3
4
5
Residual Risk, i.e. after controls are in place.
Severity
Likelihood
Residual risk
Information relevant HSE and trade publications
Comments from Line Manager
Signed
Comments from Risk Assessor
Date
Signed
Review Date
2
Date
(b) Risk Assessment Report Form
Name of Company:
Name of Assessor:
Hazards
Persons
affected
Date of Assessment:
Date of Review:
Risks
Initial Risk
Level
Existing Controls
3
Additional Controls
Action by
whom?
Action by
when?
Done
(c) Contractors’ risk assessment example for confined spaces
INITIAL RISK ASSESSMENT
SIGNIFICANT HAZARDS
1. Poisoning from toxic gases
2. Asphyxiation - lack of oxygen
3. Explosion
4. Fire
5. Excessive heat
6. Drowning
7.
8.
Work in Confined Spaces
Low
Medium
High
ACTION ALREADY TAKEN TO REDUCE THE RISKS:
Compliance with:
H S E Guidance Note - Entry into Confined Spaces
Local Authority/client safety standards, e.g. on sewer entry.
Entry into Confined Spaces Regulations 1997
The Construction (Design and Management) Regulations 2007
Dangerous 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 explosive
substances. The area will be tested before entry and continually during the presence of persons in the confined
space. Breathing apparatus or airlines will be provided if local ventilation is not possible. Where no breathing
apparatus is assessed as being required, emergency BA and rescue harnesses will be provided. Rescue
equipment including lifting equipment, resuscitation facilities safety lines and harnesses will be provided. A
communication system with those in confined space will be established. Air will not be sweetened with pure
oxygen. Precautions for safe use of any plant or heavier-than-air gases in the confined space must be established
before 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, including
first aid and operation of testing equipment. All operatives must be certified as trained and supervisory staff trained
to 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
SIGNIFICANT HAZARDS
1. Falls of persons through materials
2. Access across fragile material
3.
4.
5.
6.
7.
8.
Work on Fragile Roofs
Low
Medium
High


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 2005
H S E Guidance Booklet HS (G) 33 - Safety in Roof work
Construction (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 provide
a safe system of work taking account the work to be done, access/egress requirements and protection of the area
beneath the work area.
Physical:
Suitable means of access will be provided, such as roof ladder, crawling boards, scaffolding, and staging. Where
access 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 the
area below fragile materials while work is in progress. No person is permitted to walk upon suspected fragile
materials 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. Managers
must check risk assessments and method statements supplied by subcontractors and others, including the selfemployed, 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 be
required 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
Hazard
Hazards
Who might be
harmed?
Yes
No
Hazard
Yes
Trapping
Electrocution
Impact
Pressure
Contact
Hot/Cold
Entanglement
Fire
Ejection
Other
Operatives
Cleaners
Maintenance
Visitors
Others
Guarding
Fixed Guards
Interlocked
Movable Guards
Adjustable
guards
Fixed Distance
guard
Adequate
Enclosure of
drives and motors
Fitted to machine
Fitted to machine
Fitted to machine
Closed to run
Securely fixed
Securely fixed in
position
Design OK with
positive switches
& robust
Safe to open
Readily
adjustable
Prevent
Ejection
Maintained OK
Tool to remove
Tool required to
remove
Maintained OK
Prevents access to
danger zone
Maintained OK
Controls /Warnings/ Instructions /Training
Controls
Instruction/
Training
Area
Clearly
identified
Shrouded start
Warning signs
Lighting OK
Function clear
Warning device
Signs clear
Stability OK
Easy to use
Isolator nearby
Safety sheet OK
Ventilation OK
Emergency stop
Isolator
lockable
SOP available
LEV needed
Machine stops
ok
Permit required
Training OK
Access operators
Safe at stop
Seating needed
Access
maintenance
Action Required
SEVERITY
FREQUENCY
RISIDUAL RISK (S x F)
6
No
2- Job safety analysis form
JOB SAFETY ANALYSIS
Job
Date
Department
Carried out by
Description of job
Legal requirements and guidance
Task steps
Hazards
Consequence
/Likelihood
Severity
Safe system of work
Job Instruction
Training requirements
Review date
7
Risk
L X S
Controls
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 DETAILS
1. 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 Assessment Checklist
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 at
work. Please circle the answer that best describes your opinion, for each of the questions listed. The form
should be returned to…………………………as soon as it has been completed.
Environment
1.
Lighting
Describe the lighting at your usual workstation.
About right
Too bright
Do you get distracting reflections on your screen?
Never
Sometimes
What control do you have over local lighting?
Full control Some control
2.
Too dark
Constantly
No control
Temperature and humidity
At your workstation, is it usually:
Comfortable
Too warm
Too cold?
Is the air around your workstation:
Comfortable
3.
Too dry?
Noise
Are you distracted by noise from work equipment?
Never Occasionally
4.
Constantly
Space
Describe the amount of space around your workstation.
Adequate
Inadequate
Furniture
5. Chair
Can you adjust the height of the seat?
Yes / No
Can 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)
Furniture (continued)
Chair (continued)
Is the chair in a good state of repair?
Yes / No
If your chair has arms, do they get in the way?
Yes / No
6.
Desk
Is the desk surface large enough to allow you to place all your equipment where you want
it?
Yes / No
Is the height of the desk suitable?
Yes / Too high / Too low
Does the desk have a matt surface (non-reflectant)?
Yes / No
7.
Footrest
If you cannot place your feet flat on the floor whilst keying, has a footrest been supplied?
Yes / No
8.
Document holder
If it would be of benefit to use a document holder, has one been supplied?
Yes / No
If you have a document holder, is it adjustable to suit your needs?
Yes / No
Display Screen Equipment
9.
Display screen
Can you easily adjust the brightness and the contrast between the characters on screen and
the background?
Yes / No
Does the screen tilt and swivel freely?
Yes / No
Is the screen image stable and free from flicker?
Yes / No
Is the screen at a height, which is comfortable for you?
Yes / No
10.
Keyboard
Is the keyboard separate from the screen?
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 the
correct 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:
Lower Exposure Action Level:
80 dBA daily or weekly
Number of
Workplace
Persons
Exposed
Date of Survey:
Noise Level
(Leq)
dB(A)
Upper Action Level:
85 dBA daily or weekly
Daily
LEP'd
Exposure
dB(A)
Period
Peak Pressure:
135 dB(C)/137dB(C)
Peak Pressure
dB(C)
Comments
General Comments:
Instrument Used:
Date of Last Calibration:
Signature:
Position:
14
Date:
7 - Example of a Workplace Inspection Report Form
Workplace Inspection Cover Sheet
Name of
Company/Organization
Work area covered by
this Inspection
Activity carried out in
work place
Person
carrying
out
inspection
(PLEASE PRINT)
Date of
Inspection
(See Appendix 7.3 Inspection Checklist and Appendix 5.1 for hazard checklist)
Observations
List hazards, unsafe practices and good
practices
Priority/
risk
(H,M,L)
15
Actions to be taken (if
any)
List all immediate and
longer-term actions
required
Time Scale
Immediate
1 week etc
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?
Maintained and inspected
temporary
scaffolds
Use of mobile
elevating work
platforms
2
Access
Access ways
Housekeeping
Flooring
Working
Environment
Suitable for task?
Operators properly trained?
Properly maintained
Adequate for people, machinery and work in
progress?
Unobstructed?
Properly marked?
Stairs in good condition?
Handrails provided?
Tidy, clean, well organized?
Even and in good condition?
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?
Tasks require uncomfortable postures or
actions?
Frequent repetitive actions accompanying
Ergonomics
muscular strain?
Visual display
units
Workstation assessments needed/not needed
Chairs adjustable/comfortable/maintained
properly?
Cables properly controlled?
Lighting OK? No glare?
16
4
5
6
Welfare
Services
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 room
For pregnant or nursing mothers
Kept clean?
First aid
Suitably placed and provisioned?
Appointed person?
Trained first aider?
Correct signs and notices?
Eye wash bottles as necessary?
Electrical
equipment
Portable equipment tested?
Leads tidy not damaged?
Fixed installation inspected
Gas
Equipment serviced annually?
Water
Hot and cold water provided?
Drinking water provided?
Fire precautions Fire
extinguishers
In place? Full? Correct type?
Maintenance contract?
Fire instructions
Posted up?
Not defaced or damaged?
Fire alarms
Fitted and tested regularly?
Means of
escape/ Fire
exits
Adequate for the numbers involved?
Unobstructed?
Easily opened?
Properly signed?
Means of
escape/ Fire
exits
Adequate for the numbers involved?
Unobstructed?
Easily opened?
Properly signed?
17
PLANT AND SUBSTANCES
7
Work
Equipment
Lifting
equipment
Thoroughly examined?
Properly maintained?
Slings etc properly maintained?
Operators properly trained?
Pressure
systems
Written schemes for inspection?
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 vehicle
seats etc?
Tools and
equipment
Right tool for the job?
In good condition?
Manual
handling
Moving excessive weight?
Assessments carried out?
Using correct technique?
Could it be eliminated or reduced?
8
9
Manual &
Mechanical
Handling
Vehicles
Mechanical
handling
On site
Road risks
Forklifts and other trucks properly
maintained?
Drivers authorized and properly trained?
Passengers only where specifically intended
with suitable seat?
Speeding limits?
Following correct route?
Properly serviced?
Drivers authorized
Suitable vehicles used?
No use of mobile phones when driving?
Properly serviced? Schedules managed
properly?
18
10 Dangerous
substances
Flammable
liquids and
gases
Stored properly?
Used properly/minimum quantities in
workplace?
Sources of ignition?
Correct signs used?
11 Hazardous
substances
Chemicals
COSHH assessments OK?
Exposures adequately controlled?
Data sheet information available?
Spillage procedure available?
Properly stored and separated as necessary?
Properly disposed of?
Exhaust
ventilation
Suitable and sufficient?
Properly maintained?
Inspected regularly?
PROCEDURES
Risk
12 assessments
Carried out? General and fire?
Suitable and sufficient?
13 Safe systems
of
Work
Provided as necessary?
Kept up to date/
Followed
14
Used for high risk maintenance?
Procedure OK?
Properly followed?
Permits to
work
15 Personal
Protective
Equipment
16 Contractors
Correct type?
Worn correctly?
Good condition?
17 Notices, Signs Employers'
and Posters liability
Notice displayed? In date?
Is their competence checked thoroughly?
Are there control rules and procedures?
Are they followed?
insurance
Health and
Safety law
poster
Safety Signs
Displayed?
Correct type of sign used/
Signs in place and maintained?
19
PEOPLE
18 Health
surveillance
Specific surveillance required by law?
Stress or fatigue?
19 People's
behaviour
Are behaviour audits carried out?
Is behaviour considered in the safety
programme?
20 Training and
supervision
Suitable and sufficient?
Induction training?
Refresher training?
21 Appropriate
authorized
person
Is there a system for authorizing people for
certain special tasks like permits to work,
dangerous machinery, entry into confined
spaces?
22 Violence
Any violence likely in workplace?
Is it controlled?
Are there policies in place
23 Especially at
risk
categories
Young persons
Employed?
Special risk assessments?
New or
expectant
mothers
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 statements
should be attached where necessary. Please complete all details requested
overleaf.)
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 Personnel
within 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:
Date:...../...... /20
Personnel Manager
Health & Safety Manager
Payroll Controller
INJURED PERSON:
Surname …………………........Forenames ………………..…………............
Male/Female
Home address ………………………………………………………............................ Age…………
Consent to share this information with Safety Representatives
Employee
Signature of Injured Person............................................Date......./....../.....20...
 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
machinery or material
lifting or
asphyxiation
being machined
1
5
9
Struck by moving
including flying, or
falling object
2
 10
Struck by moving
vehicle
 3 indicate approx.
Slip, trip or fall on
same level
Contact with electricity or
an electrical discharge
 13
Exposure to or
Injured by an animal
contact with harmful
6
Fall from height
 14
Exposure to fire
7
Violence
 11
 15
Distance of fall………mtrs
Struck against
something fixed
or stationary
Trapped by something
 4 collapsing or overturning  8
Exposure to an
explosion
 12
Other kind of
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
a) by telephone ..../….../20
b) by internet
..../....../20
c) on form F2508 …./…../20
If relevant: Date reported to Enforcing Authority
Date reported to Company Insurers
…../…../20
Were the Recommendations Effective?
If No say what further action should be taken.
Yes/No
22
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 the
factors 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):
Diagrams and other information:
Locations:
People involved:
Date of assessment:
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:
23
11 - Manual Handling Risk Assessment
Manual Handling Risk Assessment Employee checklist
Task Description
Risk Factors
A. Task Characteristics
1.
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?
Employees ID No
Yes/No
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?
Details:
Yes/No
24
Risk Level
H M L
Current Controls
12- Example fire safety maintenance checklist
A fire safety maintenance checklist can be used as a means of supporting your fire safety
policy. This example list is not intended to be comprehensive and should not be used as a
substitute for carrying out a fire risk assessment.
You can modify the example where necessary, to fit your premises and may need to
incorporate the recommendations of manufacturers and installers of the fire safety
equipment/systems that you may have installed in your premises.
Any ticks in the grey boxes should result in further investigation and appropriate action as
necessary. In larger and more complex premises you may need to seek the assistance of a
competent person to carry out some of the checks.
Source: Department for Communities and Local Government Fire Safety Guides
Yes No
Daily Checks (not normally recorded)
Escape Routes
Can all fire exits be opened immediately and
easily?
Are fire doors clear of obstructions?
Are escape routes clear?
Fire warning systems
Is the indicator panel showing ‘normal’?
Are whistles, gongs or air horns in place?
Escape lighting
Are luminaries and exit signs in good condition
and undamaged?
Is emergency lighting and sign lighting working
correctly?
Firefighting equipment
Are all fire extinguishers in place?
Are fire extinguishers clearly visible?
Are vehicles blocking fire hydrants or access to
them?
Weekly checks
Escape routes
Do all emergency fastening devices to fire exits
(push bars and pads, etc.) work correctly?
Are external routes clear and safe?
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N/A Comments
Yes No
Weekly checks continued
Fire warning systems
Does testing a manual call point send a signal to
the indicator panel? (Disconnect the link to the
receiving centre or tell them you are doing a
test.)
Did the alarm system work correctly when
tested?
Did staff and other people hear the fire alarm?
Did any linked fire protection systems operate
correctly? (e.g. magnetic door holder released,
smoke curtains drop)
Do all visual alarms and/or vibrating alarms and
pagers (as applicable) work?
Do voice alarm systems work correctly? Was
the 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 escape
doors work correctly? Do they ‘fail safe’ in the
open position?
Do all automatic opening doors on escape
routes ‘fail safe’ in the open position?
Are fire door seals and self-closing devices in
good condition?
Do all roller shutters provided for fire
compartmentation work correctly?
Are external escape stairs safe?
Do all internal self-closing fire doors work
correctly?
Escape lighting
Do all luminaries and exit signs function
correctly when tested?
Have all emergency generators been tested?
(Normally run for one hour.)
Fire fighting equipment
Is the pressure in ‘stored pressure’ fire
extinguishers correct?
Additional items from manufacturer’s
recommendations.
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N/A Comments
Yes No
Three-monthly checks
General
Are any emergency water tanks/ponds at their
normal capacity?
Are vehicles blocking fire hydrants or access to
them?
Additional items from manufacturer’s
recommendations.
Six-monthly checks
General
Has any fire fighting or emergency evacuation
lift been tested by a competent person?
Has any sprinkler system been tested by a
competent person?
Have the release and closing mechanisms of
any fire-resisting compartment doors and
shutters been tested by a competent person?
Fire warning system
Has the system been checked by a competent
person?
Escape lighting
Do all luminaries operate on test for one third of
their rated value?
Additional items from manufacturer’s
recommendations.
Annual checks
Escape routes
Do all self-closing fire doors fit correctly?
Is escape route compartmentation in good
repair?
Escape lighting
Do all luminaries operate on test for their full
rated duration?
Has the system been checked by a competent
person?
Fire fighting equipment
Has all fire fighting equipment been checked by
a competent person?
Miscellaneous
Has any dry/wet rising fire main been tested by
a competent person?
Has the smoke and heat ventilation system
been tested by a competent person?
Miscellaneous continued
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N/A Comments
Yes No
Has external access for the fire service been
checked for ongoing availability?
Have any fire-fighters’ switches been tested?
Has the fire hydrant bypass flow valve control
been tested by a competent person?
Are any necessary fire engine direction signs in
place?
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N/A Comments
13- Example Fire risk assessment record of significant findings
Risk Assessment – Record of significant findings
Fire Risk Assessment – Record of significant findings
Risk assessment for
Company
Assessment undertaken by
Date
Address
Completed by
Signature
Sheet number
Step 1 - Identify fire hazards
Sources of ignition
Floor/area
Use
Sources of fuel
Sources of oxygen
Step 2 – People at risk
Step 3 – Evaluate, remove, reduce and protect from risk
(3.1) Evaluate the risk
of the fire occurring
(3.2) Evaluate the risk to
people from a fire starting
in the premises
(3.3) Remove and reduce
the hazards that may
cause a fire
(3.4) Remove and reduce
the risks to people
from 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 with other ‘responsible
persons’ in the building; and to inform and train staff and inform other relevant persons.
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14 - Construction Inspection Report Form
Construction Inspection Report
1. 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 making
the report.
11. Date and time report handed over.
12. Name and position of person
receiving report.
94
I
Safety at work
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