Company Details
Company Name:
Contact Name:
Address:
Telephone No:
Fax No:
Mobile:
Email:
Trade
Please tell us what your primary works are:
......
Other Details
Company reg no:
VAT No:
UTR No:
(If sole trader) NI No:
YesNo
Are you a member of any trade association?
(If yes please provide copies of certificates)
Please enclose examples of site specific risk assessments completed in the last 12 months
Please enclose examples of site specific method statements completed in the last 12 months
Please give details of your onsite arrangements for monitoring your staff to ensure the task is completed safely?
......
Please provide the name, qualification and or experience of your internal health and safety co-ordinator. If you also use an external source please provide full details:
Internal-
External-
Yes No
Do you issue your staff with appropriate PPE for the job?
(If no please justify the reasons for not adhering to the requirements of the Personal Protective Equipment at Work Regulations 1992 as amended)
How do you ensure all equipment used on site is well maintained and safe for use? Please enclose recent PAT test records?
YesNo
Do you appoint sub-contractors?
(If yes please provide details of how you assess your sub-contractors)
How do you monitor the performance of your sub-contractors?
......
Training
Please tell us if you have attended any of the following training courses (if you have completed any of the following please provide certificates)
YesNo
PASMA
IPAF
SMSTS/SSSIC
Health & Safety Awareness
PAT/GAS Tools
Asbestos Awareness
First Aid
Steps and Ladders
Any other training courses
......
Health & Safety
Please state how many of the following you have reported under RIDDOR in the last 3 years:
Occurrence / Year 1 / Year 2 / Year 3 / This year to dateMajor Injuries
Over 3 Day Injuries
Dangerous Occurrences
Reportable Diseases
YesNo
Have you been served with any improvement notice within the last 3 years?
(If yes please provide details on a separate sheet)
Yes No
Have you been prosecuted for a Health & Safety offence in the last 3 years?
(If yes please provide details on a separate sheet)
Please include the following with this form (please tick):
YesNoAlready supplied
Health & safety policy:
Insurance certificates:
Staff CSCS card copies:
Geographical area of work:
Please tick
ScotlandNorth Wales
South WalesNorth West
North EastWest Midlands
East MidlandsSouth West
South East
Please tell us the minimum and maximum values of work you will undertake
Minimum£Maximum£
References
Please provide two references of work completed in the last 2 years
Ref 1:
Job:
Date completed:
Work done:
Value:
Company name:
Contact name:
Address:
Telephone No:
Email:
Ref 2:
Job:
Date completed:
Work done:
Value:
Company name:
Contact name:
Address:
Telephone No:
Email:
Any other comments you wish to include:
Signed:
Printed (block capitals):
Date:
Thank you for your time
Please send to:
Health & Safety Dept
The Ceiling & Partition Company Ltd
Unit 52 Winpenny Road
Parkhouse Industrial Estate East
Newcastle-under-Lyme
ST5 7RH
Or
Email to:
FAX TO: 01782 566043
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