WORK PLACEMENT HEALTHAND SAFETYCHECKLIST

ProviderDetails
Nameand
address: / KingstonMaurward College
Dorchester
DorsetDT2 8PY / Telephone No:
Fax No: / 01305215000
EmployerDetails
Employer’sname: / Contactname:
Workplaceaddress: / Position:
Postcode: / H&Scontact:
Occupationalarea: / Telephonenumber:
Numberof
employees: / Faxnumber:
Numberoflearners / Emailaddress:
Typeofworkcarried outatworkplace
location:
Enforcementaction
(prosecutions, noticesetc):
Healthandsafety
committee/safety representation:
Checklist Completion
Checklistcarried outby(WBLCor
WBLA):
Datechecklist
carriedout:
Accompaniedby:
Riskrating: / Unacceptable / / High / / Medium / / Low /
ReviewCriteria / RejectEmployer / Formalreviewor
re-issueafter1 year / Formalrevieworre- issueafter2years / Formalrevieworre- issueafter3years
Revisitevery3-monthsduringmonitoringvisitsandreviewActionList
Datecopyissued
toEmployer:

InternalUseOnlyby Work-BasedLearningAdministrator

Enteredon PICs / By: / Date:
QualityCheck: / Issuedto: / Date:

FormRef:KMS554/01

July 2013 – Reviewed July 2016

HEALTH & SAFETYPROCUREMENT STANDARDS(HASPS)

1 / HealthandSafetypolicy / Yes / No / Evidence/ comments
1.1 / Does the workplace have a written H&S policy? (legally required if more than 5employees) & has it been reviewed in the last 12 months / /
1.2 / Aretheresponsibilitiesforhealthandsafety
clearlystated?(should be on display if5 ormore employees) / /
1.3 / Arearrangementsforhealthandsafetyclearly
stated(recordedwhen5 or moreemployees)? / /
1.4 / Howarethecommitment,responsibilitiesand
arrangementsforhealthandsafety(above)communicatedtoemployees?
2 / Riskassessmentandcontrol
Type of risk assessment / Haverisk assessmentsbeencarriedout? / Haverisk assessmentsbeenrecorded? / Haveappropriatecontrolmeasuresbeenidentifiedandputintoplace?
Yes / No / Yes / No / Yes / No
2.1 / Health & Safety Risk Assessment
(covering work related activities) / / / / / /
2.2 / COSHH / / / / / /
2.3 / DisplayScreenEquipment / / / / / /
2.4 / ManualHandling / / / / / /
2.5 / Noise / / / / / /
2.6 / Fire / / / / / /
2.7 / YoungPersons / / / / / /
2.8 / Other-pleasespecify(e.g.dust,vibration,bio-hazards,radiationsources,asbestos):
2.9 / Followingrisk assessmentsabove,aresafesystemsof work inplace? / Yes / / No /
2.10 / Areanyhealthsurveillancechecksrequiredfor employees/learners / Yes / / No /
?Ifso,howare theseprovisionsundertaken?
2.11 / Howaretherisksandcontrolmeasures explainedto employees/learners?
2.12 / Commentsonanyof2.1to 2.11
3 / Accidents,incidentsandfirstaid / Yes / No / Evidence/ comments
3.1 / Aresuitablefirstaidsuppliesavailable? / /
3.2 / Haveadequatearrangementsfortrainedfirst
aidpersonsbeenmade? / /
3.3 / Howareaccidents/incidentsrecorded?
3.4 / Employerunderstandsaccidentreporting procedure? / /
3.5 / Whois thecompetentpersonresponsiblefor
investigatingaccidentsand near-misses?
3.6 / Hastheemployerasysteminplaceto
investigateaccidentsandtakeactiontoprevent re-occurrence? / /
Is there a system in place for accidents and near-misses concerning apprentices to be copied to KMC? / /
3.7 / Howarethearrangementsforaccidents,
incidents,ill-healthandfirstaidmadeknownto allemployeesandlearners?
4 / Supervision,training,informationand
instruction / Yes / No / Evidence/ comments
4.1 / Areemployees/learnersprovidedwithadequate
competentsupervision? / /
4.2 / Is initialhealthandsafetyinformation, instructionandtraininggiventoall new
employees/learnersonrecruitment? / /
4.3 / Isongoinghealthandsafetyinformation, instructionandtrainingprovidedtoall employees/learners? / /
4.4 / Ishealthandsafetyinformation,instructionand
trainingrecorded? / /
4.5 / Isadequatesafetysignageinplace? / /
5 / Workequipmentandmachinery / Yes / No / Evidence/ comments
5.1 / Iscorrectmachineryandequipmentprovidedto
theappropriatestandards(PUWERcompliant)? / /
5.2 / Isequipmentadequatelymaintained? / /
5.3 / Areguardsandcontrolmeasuresinplaceas
determinedthroughrisk assessment,including specificrisks? / /
5.4 / Aresafeelectricalsystemsandequipment providedandmaintained? / /
6 / Personalprotectiveequipment(PPE) / Yes / No / Evidence/ comments
6.1 / IsappropriatePPEprovided,freeofcharge,to
employees/learners? / /
6.2 / Istrainingandinformationonthesafeuseof
PPEprovidedtoallemployees/learners? / /
6.3 / IstheproperuseandstorageofPPEenforced? / /
6.4 / Is PPEmaintainedandreplaced? / /
7 / Fireandemergencies / Yes / No / Evidence/ comments
7.1 / Isthereameansofraisingthealarm andfire
detectioninplace? / /
7.2 / Arefireextinguishers/blankets/hoses
appropriateandservicedannually? / /
7.3 / Aretheappropriatefiredrillsandtestscarried out? / /
7.4 / Isthereafirelog/recordbookkept? / /
7.5 / Areeffectivemeansofescapeinplaceincluding
unobstructedroutesandexits? / /
7.6 / Isthereanamedpersonforemergencies? / /
8 / Safeandhealthyworkingenvironment / Yes / No / Evidence/ comments
8.1 / Arepremises(structure,fabric,fixturesand
fittings)safeandsuitable(maintainedandkept clean)? / /
8.2 / Isthetemperature,lighting,space,ventilation,
andnoisesatisfactorilycontrolled? / /
8.3 / Are welfarefacilities(toilets,washing,drinking,
eating,changing)providedasappropriateand maintained? / /
9 / Generalhealthandsafetymanagement / Yes / No / Evidence/ comments
9.1 / Howdoestheemployerconsultand
communicatewithemployees/learnersand allowthem toparticipateinhealthandsafety?
9.2 / Doestheemployerhaveaccesstocompetent healthandsafetyadviceandassistance? / /
9.3 / Doestheemployerreviewhealthandsafety
annually? / /
9.4 / IstheHealthandSafetyLawposterdisplayed
(orleafletsgiventoeachemployee)? / /
9.5 / IstheEmployerLiabilitycertificatedisplayed andindateoravailableonanIT system? / /
9.6 / Employer/PublicLiabilitydetails
CombinedPolicy
SeparatePolicies / Nameof insurer:
Policynumber: Expirydate:
9.7 / Howdoestheemployermanage
employees’/learners’workwhenitis awayfrom theemployer’sownpremisesor when employeesareplacedwith another employer/site?
9.8 / Howdoestheemployerassess,reviewand
updateemployees’/learners’capabilities?
/ HEALTH & SAFETYSTANDARD10 for ACF placements
Learner’sName: / Employer’sName:
Learner’sWorkLocation(s): / EmergencyContact:
Typeofcheck: / Workbased
learning / / Work
experience? / / Learnerunder
18? / / Learnerunder
16? /
Hasthe‘SaferLearning,Safer
Working’sheetbeenissuedand
discussedwiththeapprentice? / YES
/ NO
/ Hasthe‘Informationfor
SafeguardingChildrenand VulnerableAdults’sheetbeen issuedanddiscussedwiththe employer? / YES
/ NO

10 / Managementoflearner’s/youngperson’s
healthandsafety / Evidence/ comments
A / Hastheemployerassessedtheriskstothe
learner/youngpersontakingintoaccounttheir age,inexperience,immaturityandlackof awarenessofrisks?
B / Havetheassessmentstakenintoaccountany
otherspecialneedsorcircumstancesincluding anydisabilityand/ormedicalhealthcondition?
C / Hastheemployerput inplacecontrolmeasures forthelearner/youngpersonasaresultof the
assessmentsandhavetheyinformedthe learnerandtheirsupervisor(s)?
D / Detailanynecessaryprohibitionsand
restrictionsidentifiedbytherisk assessments thatapplytothelearner/youngperson
E / Doestheemployerprovidecompetent supervisionforlearners/youngpersonsanddo
theyhaveadesignatedpersontotakeoverall responsibilityforthem?
F / Doestheemployerprovideaninductionforthe
learner/youngperson?
G / Doestheemployerprovideinstructionand
trainingto learners/youngpersonreflectingthe findingsoftherisk assessment,working environment,work activities,age,experience andanyspecialneeds?
H / Doestheemployerprovide,freeofcharge,any
necessarypersonalprotectiveequipmentand clothing(asdeterminedbytherisk assessment) andensureitsproperandeffectiveuse?
I / Please note that it is KMC policy that all learners must have the appropriate training/qualifications before operating any ATV / Quad bike (both on and off the road), Tele-handler or Skid-steer Loader in the workplace.
You should be aware that not following the above recommendations could invalidate your company’s insurance.
Employer:I confirmthatIhavenopriororpendingconvictionsthatwouldpreventmefrom workingwithchildrenunder
theageof18.I understandthatI amresponsibleforthesupervisionandsafeguardingof studentsworkingon placement.IhavereceivedacopyoftheCollege’sprocedurestofollowshouldI haveanysafeguardingorchild protectionconcerns
.
Agreed by (Print name)
Employer (Print name) / Signature
Date

FormRef:KMS554/01

July 2013 – Reviewed July 2016

ACTION PLAN FOR INDIVIDUAL LEARNER
Action required / Bywho / Target date / Completed
(signed off)
Action plan preparedby
(WBLC/WBLA): / Agreed by(Learner):
Signed (Employer): / Date:
Action planreviewdates:

FormRef:KMS554/01

July 2013 – Reviewed July 2016

ACTION PLAN FOR THE EMPLOYER
Action required / Bywho / Target date / Completed
(signed off)
Action plan preparedby
(WBLC/WBLA): / Agreed by(Employer):
Signed: / Date:
Action planreviewdates:

FormRef:KMS554/01

July 2013 – Reviewed July 2016

OCCUPATIONAL RISK BANDING

High
Agriculture / Medium
Animal Care(includingRetail) / Low
Administration
Animal Nursing / Care / Education
Catering(Kitchen) / Electronics / RetailTrade
Chemical& ChemicalProducts / Hairdressing Beauty / Sales
Construction / Printing
Engineering(Mechanical &Electrical) / Hotel &Restaurants(non-catering)
Equestrian / Sport/Recreation
Fishing / Textiles/Clothing
Forestry / Wholesale
Horticulture / Warehousing
Manufacturing/Craft / Sport/RecreationLeisure
Mining/Quarrying
Outdoor Pursuits
Repair ofMotor Vehicles &Motorcycles
Security
Transport
Utilities
OrganisationRiskDefinitionsforPlacements
LowRisk: / Demonstration ofhighstandardsofhealthsafety.Detailedevidenceofcompliance withhealthsafetycontractualrequirements.
MediumRisk: / Demonstrationofbasicstandardsofhealthandsafety.Minimumlevelofcompliance with health and safety contractual requirements. Improvements required in accordancewithanagreeddevelopmentplan
HighRisk: / Demonstrationofpoorstandardsofhealthandsafety.Insufficientcompliancewith healthandsafety contractualrequirements. Significantimprovementsnecessary, unacceptableuntilaDevelopmentPlanwithstricttimescaleshasbeenagreedand initiated.
Unacceptable / The organisation’s attitude and/or non-compliance with health and safety requirements determinetheplacementunacceptable. UnabletoagreeDevelopment Plan

Thepurposeof vettingis toensurethatthelearneris placedinasafeenvironmentandis notexposedto unduerisks.

LearnernottobeplacedwithanemployerwithacombinedriskbandofUnacceptable.

Itis importantto includeajudgementregardingtheemployer’sattitudetowardshealth,safetyandwelfarebeforedecidingontheorganisationrisk banding.

FormRef:KMS554/01

July 2013 – Reviewed July 2016

11 / Risk Rating
Circle appropriateOccupational andOrganisational RiskLevel
Highest Occupational Risk Level
Low / Medium / High
Organisation RiskLevel / Low / Low / Low / Medium
Medium / Low / Medium / High
High / High / High / High
Unacceptable / Unacceptable
12 / Placement combinedrisk rating
HighMediumLowUnacceptable
Combinedriskrating
N.B. Include combinedrisk ratingonthefront page ofchecklist
13 / Declaration –The Employeror theirrepresentative
Wecertifythat theinformation recorded onthischecklist was accurate at the timeofchecking
Signed:
Date:
Print Name:
Position/Job Title:
Employer’s Comments
14 / Declaration
Assessment
undertaken by:
Signed:
Date:
Job Title:
15 / QualityAssurance(forcompletionbythe Health,Safety& WelfareAdviser)
QualityCheckedby:
Date:
Signature:
Job Title:
QualityImprovement
Plan Issued? / Yes (see actionsheetattached)No
Issuedto: / Date Issued:
QIPRef(ifapplicable)

FormRef:KMS554/01

July 2013 – Reviewed July 2016