Are there any specific risks, eg working with:

Hazardous substances

Dangerous tools

Dangerous machinery

Dangerous loads or animals

If so, give a brief description

Are there parts of your establishment where different levels of risk can be identified (eg in a University with research laboratories)?

Yes    No

If Yes, give a brief description of the various work areas

What is your record of accidents and cases of ill health? What type are they and where did they happen?

 

How many people are employed on site?

 

1 to 10 11 to 30 31 to 50 51 to 100 over 100

Are there inexperienced workers on site, or employees with disabilities or special health problems?

       Yes    No

If Yes, give a brief description

Are the premises spread out, eg are there several buildings on the site or multi-floor buildings?

        Yes    No

If Yes, give a brief description

Is there shiftwork or out-of-hours working?

        Yes    No

If Yes, give a brief description

Is your workplace remote from emergency medical services?

       Yes    No

If Yes, how far is it to the nearest A&E.

1 to 3 miles 4to 10 miles over 10 miles

Do you have employees who travel a lot or work alone?

      Yes    No

If Yes, how many 1 to 10 11 to 30 31 to 50 51 to 100 over 100

Do any of your employees work at sites occupied by other employers?

       Yes    No

If Yes, give a brief description

Do you have any work experience trainees?

       Yes    No

If Yes, give a brief description

Do members of the public visit your premises?

        Yes    No

If Yes, give a brief description

Title  Mr Mrs Ms Dr Sir

Name 

Email address

Tele No