HEALTH AND SAFETY QUESTIONNAIRE

HELP US TO HELP YOU

Environmental Health Unit

CONFIDENTIAL QUESTIONNAIRE Please complete the questionnaire by giving details or ticking boxes as appropriate. WHAT TO DO IF YOU NEED HELP If you find that you require further advice or assistance in completing this document, please feel free to contact this Unit on 01305 838432. For Official Use 1. 2. 3. BUSINESS DETAILS Name of business: Trading name: Sole trader Charity 4. Address: Partnership Company Limited Co. Other

5. 6.

Telephone number: Head office address:

7. 8. 9. 10.

Telephone number: Name of person completing questionnaire: Your position / job title: Please describe the MAIN ACTIVITY i.e. main purpose of the business at the above named premises

For Official use Workplace Workplace Health, Safety and Welfare 11. What is the number of employees at the premises at peak time? Full-time female: Priced publications (only available at HSE BOOKS) Tel: 01787 881165 OR EMAIL: www.hsebooks.gov.uk (1) Management of Health and Safety at Work Regulations 1999 Approved Code of Practice and Guidance L21 (second edition) ISBN 0 7176 2488 9 Workplace (Health, Safety and Welfare Regulations 1992, Approved Code of Practice and Guidance L24 ISBN 0 7176 04136 VDUs: An Easy Guide to the Regulations HSG90 ISBN 0 7176 0735 06 Yes (4) Health and Safety Law Poster ISBN 0 7176 2493 5 13. Addresses to be put on Health and Safety Law Poster Enforcing Authority Weymouth & Portland Borough Council Environmental Health Unit Council Offices North Quay Weymouth Dorset DT4 8TA Tel: 01305 838432 Fax: 01305 766684 Employment Medical Advisory Service (EMAS) Health and Safety Executive Intercity House Mitchell Lane Victoria Street Bristol BS1 6AN Tel: 01179 886000 15. Do you have an accident book or similar accident record system? Yes No If YES have you adequately assessed their safety and controlled any hazards that may cause them injury? Yes ACCIDENTS 14. Do you know which accidents and dangerous occurrences are legally required to be reported to the Environmental Health Unit on Form F2508? Yes No No No Full-time male: Part-time female: Part-time male: Self employed female: Self employed male:

Young employees/Trainees (16-18 yrs) Employee/Trade Union Representative: Employers Liability Insurance: 12. Yes Yes No No

(2)

Do other persons who are not employees visit your work premises (including contractors or clients or members of the public)?

(3)

Significant entries (e.g. several similar accidents in 6 months; major accidents/ incident?) HSE Main Website: www.hse.gov.uk HMSO website: www.legislation.hmso.gov.uk 16. Other sites: Yes www.nuneatonandbedworth.gov.uk/business/healthsafety 17. Are there any trained first aiders? Yes 18. No No Do you have a first aid kit?

Are there one or more appointed persons trained to seek medical help in an emergency situation? Yes No 2

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For Official Use 19. Please calculate your companies injury incident rate (see note). Step 1 Calculate the total number of reportable injuries in the year Step 2 - Times this number by 100,000 Step 3 - Divide the total by your number of employees Reportable injuries x 100,000 Number of employees NOTE: Reportable injuries (RIDDOR) include major injuries e.g. broken leg, fractured skull and over 3 days off work injuries or cannot carry out normal duties due to injuries FIRE PRECAUTIONS AND EMERGENCY EVACUATION 20. Have all relevant persons been trained about the action to be taken on discovering a fire or when a warning of a fire is given or any other emergency situation? Yes 21. No Hazardous Substances General Health and Safety Accidents Asbestos Electrical

EXAMPLE LIST OF FREE HEALTH AND SAFETY LEAFLETS Please tick the boxes of any that you would like us to send RIDDOR Explained Managing Asbestos in Workplace Buildings Electrical Safety and You Maintaining Portable Electrical Equipment in Offices and Other Low Risk Environments First Aid at Work Your Questions Answered Gas Appliances Get Them Checked, Keep Them Safe Be safe The Costs of Accidents A Guide for Small Firms Health and Safety at Work etc. Act 1974, Advice to Employers and safety Managing Health and Safety Five Steps to Success Officewise What to Expect When a Health and Safety Inspector Calls COSHH A Brief Guide to the Regulations

First Aid Gas

Do you provide the correct portable fire extinguisher(s) at the premises? Yes No

22.

Do you use flammable liquids or bottled gases in your business? Yes No

Health and Safety Documentation Lifting Equipment Manual Handling Risk Assessment Slips and Trips

5 Steps to Risk Assessment Starting Your Business

If Yes, do you provide safe storage for them? Yes No

Simple Guide to the Lifting Operations and Lifting Equipment Regulations 1998 Getting to Grips with Manual Handling A Short Guide for Employees Five Steps to Risk Assessment INDG163 Five Steps to Information, Instruction and Training INDG213 Managing Health and Safety: Five Steps to Success INDG275 Starting Your Business Guide on Preparing a Health and Safety Policy document INDG324 Consulting Employees on Health and Safety A Guide to the Law INDG232 Help on Work Related Stress A Short Guide Violence at Work A Guide for Employers Working with VDUs Simple Guide to the Provision and Use of Work Equipment Regulations 1998 Working Alone in Safety Controlling the Risks of Solitary Work 12

IF YOU DO NOT EMPLOY ANYONE YOU ARE NOT REQUIRED TO FILL IN THE REST OF THE QUESTIONNAIRE, SIMPLY RETURN THE ABOVE INFORMATION IN THE SAE PROVIDED. YOUR SAFETY POLICIES 23. Has your business produced a written company safety policy? (Not applicable if less than 5 employees at all company locations) Yes No Not applicable

Stress Violence

If Yes, does it include:Statement of general policy Organisation: Arrangements: Signed and reviewed Please state last revision date: 3 Yes Yes Yes Yes No No No No

VDU Work Equipment Working Alone

For Official use If you have any further comments to make or wish to provide additional information, please give the details below: 24. Have you carried out a risk assessment at the premises (i.e. identified hazards and worked out the associated risk)? Yes 25. No

If so, have you produced a record of all the significant findings? Yes No Not applicable (if less than 5 employees at all company locations

What are the main findings?

26.

Is a Health and Safety Law What You Should Know Poster displayed or leaflets distributed at the premises? Yes No

27.

Do you have any staff who work alone e.g. van drivers, staff who visit other locations alone etc? Yes No

If Yes, what are the safe working arrangements and emergency procedures in place for these workers:

THANK YOU, YOU HAVE NOW COMPLETED THE SELF ASSESSMENT QUESTIONNAIRE A list of leaflets that are available on these subjects can be found on pages 12 and 13. Alternatively you can visit the HSE Books website (see page 13) Please tick the relevant boxes if you wish to receive the information. 11 4

For Official Use INFORMATION, INSTRUCTION, SUPERVISION, TRAINING AND CONSULTATION 28. Is there employee health and safety induction training? 64. Yes 29. No Yes Do staff receive refresher health and safety training 65. Yes 30. No Yes Do you consult employees about their health and safety concerns? Yes 31. No If No, do you provide a smoke free staff room or rest area with seating? Yes 66 No No Are there any restrictions on smoking at work? No Is it possible for staff to make a hot drink? 63. Do you provide drinking water? (This will include mains tap water.) Yes No

For Official Use

Are you satisfied that people requiring specific health and safety information, instruction, supervision, training and consultation have received it? E.g. on dangerous machinery. Yes No

Have you made provisions for pregnant women and nursing mothers to lie down if they need to? Yes No

32.

Have you provided employees with other written health and safety Information? Yes No

STRESS 67. Have you undertaken a stress risk assessment in the workplace? Yes No

WORKPLACE HAZARDS 33. Do you have pressurised appliances at the premises? E.g. boiler, coffee machine, air compressor? Yes No

If Yes, what arrangements have been made to combat stress at work?

W

If Yes, are your pressurised appliances maintained and tested by a competent person (e.g. insurance engineer) at least yearly? Yes 34. No

Do pedestrians and vehicles move around in the same area? Yes No Not applicable

35.

Is there a loading bay or similar? Yes No

If Yes, please explain the safety arrangements in place for moving/unloading/reversing etc.

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For Official Use HARMFUL SUBSTANCES 59. Do you use or store harmful substances such as those labelled as toxic, Harmful, irritant or corrosive? (Other than normal quantities of domestic Cleaning materials) 37. Yes No 36. Does the premises have an intermediate floor or high level storage area more than two metres off the ground which people must use? Yes No

For Offic ial use

Are you satisfied that all dangerous parts of work equipment are adequately guarded? Yes No Not applicable
SH

If Yes, please give brief details of the harmful substances present at your premises, the amounts of these substances and whether they are only stored at the premises or are in use by staff? Substances Where stored: How are they used: Is personal protective equipment Required?

38.

Is lifting equipment thoroughly examined by a competent engineer every 12 months? (6 months for passenger lifts) Yes No There is no lifting equipment

WORKPLACE RISKS 39. Are services such as mechanical ventilation systems in good repair and regularly maintained? Yes 40. No

ASBESTOS 60. If there is a possibility that asbestos exists within the building, have you carried out a survey to find out whether asbestos is present in the building? Yes No Not applicable

Is all the flooring in good condition, free from holes, is even and not slippery? Yes No

41.

Are all staircases to the premises well constructed with a handrail provided on at least one side? Yes No Not applicable

If Yes, are maintenance personnel including contractors informed of its presence and is any work undertaken done in accordance with the Control of Asbestos at Work Regulations? Yes No

42.

Are staircases, walkways and fire exits always kept free of obstructions which could cause a person to trip or fall? Yes No

WORKING TIME REGULATIONS 61 Do you employ anyone who works over 48 hours per week?

43.

Are all shelving and racking units well made and strong enough for the loads placed on them? Yes No

Yes WELFARE 61.

No

HH

44. How many toilets and non WC hand washing facilities are there? Female Male Unisex Non WC hand wash basins 45.

Are you satisfied that your premises is provided with safe means of reaching heights such as a commercially rated step-ladder or kick-stool? Yes No

Are you satisfied that windows or external doors higher than the ground floor can be opened without danger? Yes No Not applicable 6

For Official Use 54. 46. Do the workrooms have enough free space to allow people to move about with ease? Yes 47. No 55. Are you satisfied that the workplace is kept clean? Yes No

For Official Use

HR

Are you satisfied that all waste is stored in suitable bins which are emptied Regularly? Yes No

Do you have a safe system of work for window cleaning and other cleaning/maintenance tasks at high level? Yes No Not applicable 56.

Are you satisfied that all workstations (i.e. desks, benches, counters) and Seating are suitable for the people using them and for the work? Yes No

48.

Is your portable electrical equipment (any appliance fitted with a plug) regularly inspected and maintained? Yes No 57.

Do any staff regularly use a computer continuously for at least 2 hours per day? Yes No

If Yes, how is the equipment checked? By an electrician Visual inspection only With our own PAT equipment Other

If Yes, do you provide: Yes Suitable desks with enough room for all the equipment? Modern, fully adjustable 5-point chairs? Enough room around each desk? Monitors with adjustable controls? Suitable keyboards or mouse controls? Computer equipment which is adjustable in height, tilt and layout? Free eye-tests with an optician? Regular breaks for staff away from the screen? Adequate lighting, free from glare or distracting reflections? Information to staff about the problems of poor posture and fatigue? MANUAL HANDLING
SR

No

If Yes, how often is the equipment tested? 49. Is the fixed electrical installation in the building regularly inspected and maintained? Yes No

If Yes, how often? 50. Is all equipment used at work safe to use Yes No 58.

Are there any people who must carry heavy goods or awkward items such as Stationery or stock deliveries, drink containers or items of work equipment? Yes No

WORKPLACE HEALTH 51. Are you satisfied that all workrooms are adequately ventilated? Yes No

If Yes, what is/are the main manual handling tasks?

If Yes, how are workrooms ventilated? Openable windows 52. Mechanical ventilation system

Are you satisfied that the workroom temperature is comfortable? Yes No

53.

Are you satisfied that there is sufficient lighting to enable people to work and move about safely? Yes No 8