Contractors Health and Safety Form

Date: ______

Job Detail: ______

Job Location: ______

Plant: ______

Description of work to be

carried out including any

special tools to be used. ______

Company carrying out work: ______

ASBESTOS

Is an Asbestos management survey available on site? YES / NO

Ensure contractors review survey and observe any asbestos types and its location. YES / NO

If any construction works involve disturbing the fabric of the building then a specific

asbestos refurbishment survey must be undertaken prior to any works being undertaken. YES / NO

All contractors must be questioned to ensure they have undertaken asbestos

awareness training within the last 12 months. YES / NO

If none of the above then STOP WORK

HAZARDS AND PRECAUTIONS TO BE TAKEN

Contractor to complete – Please answer the following questions truthfully.

Is a facility closure required? YES / NO / N/A

Are you qualified / trained to undertake this work? YES / NO / N/A

Do you have appropriate Personal Protective Equipment for the task? YES / NO / N/A

Are all tools and equipment safe and suitable for the job? (Battery or 110v operation) YES / NO / N/A

Are all warning signs and barriers in place? YES / NO / N/A

Are all service isolation valves / switches clearly identified? YES / NO / N/A

Is it safe to work alone? YES / NO / N/A

Are regular checks in place for lone workers? YES / NO / N/A

Is there a means of mobile communication in place? YES / NO / N/A

Are emergency plans in place? (Fire and Medical) YES / NO / N/A

Are you aware of all services in the vicinity? YES / NO / N/A

Have all services been disconnected / isolated and proved safe? YES / NO / N/A

Will work area be cordoned? YES / NO / N/A

Are all relevant staff aware of activity? YES / NO / N/A

IMPORTANT If you discover asbestos STOP WORK and consult us.

Other precautions required: ______

Other safety equipment required: ______

Business Manager to complete – Please ensure these questions are completed before work starts.

Is there a risk assessment and method statement for the job?

If yes please attach it to this sheet. YES / NO

Has the contractor read the fire procedures?

If no do not let the contractor start work. YES / NO

Has the contractor read the risk assessment(s)?

If no do not let the contractor start work. YES / NO

Has the contractor been issued with an ID badge?

If no do not let the contractor start work. YES / NO

Is the contractor doing Hot works? YES / NO (If you require advice on hot works please contact the Health and Safety team)

Is the contractor working in a confined space? YES / NO

(If you require advice on hot works please contact the Health and Safety team)

Is the contractor working on electrical / mechanical plant that requires a lock off? YES / NO

(If you require advice on hot works please contact the Health and Safety team)

AUTHORISATION AND ACCEPTANCE

I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above. I accept responsibility.

PERSON IN CHARGE: ------PLEASE PRINT------

(CONTRACTOR)

COMPANY: ------PLEASE PRINT------

SIGNATURE: ------PLEASE PRINT------DATE: DD / MM / YY

SITE / DUTY MANAGER: ------PLEASE PRINT------TIME: ……. HH ……. :MM

This form is only valid when all section are complete.

Do not proceed with any building maintenance work until you have completed the first section of this form.

If you are in doubt or don’t understand, then please ask. Remember, all accidents are preventable and it is people who get hurt and suffer pain. Please use this form in the spirit intended to protect yourself and others.

Do not proceed with your work until the work has been authorised by the relevant staff member.

CHECKS TO BE CARRIED OUT ONCE WORK HAS STARTED

Check to ensure the contractor is working safely.

Are the contractors working from the risk assessment? YES / NO

SIGNATURE: ______DATE: DD / MM / YY

PRINT NAME: ------PLEASE PRINT------TIME: ……. HH ……. :MM

AUTHORISATION AND ACCEPTANCE

After the work has been completed – The work has been completed to a satisfactory standard and the area has been left in an acceptable condition.

Is the work completed? YES / NO

Is the area safe? YES / NO

Has the ID badge been returned? YES / NO

PERSON IN CHARGE: ------PLEASE PRINT------

COMPANY: ------PLEASE PRINT------

SIGNATURE: ------PLEASE PRINT------

SITE / DUTY MANAGER: ------PLEASE PRINT------

Does the contractor have any medical conditions we need to be made aware of YES / NO
If yes please provide details:
N.B. All medical information will be kept strictly confidential.
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