HEALTH AND SAFETY

QUESTIONNAIRE

HELP US TO HELP YOU

Environmental Health Unit CONFIDENTIAL QUESTIONNAIRE

details or ticking boxes as appropriate. Please complete the questionnaire by giving

WHAT TO DO IF YOU NEED HELP

or assistance in completing this document, If you find that you require further advice

please feel free to contact this Unit on 01305 838432.

For

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BUSINESS DETAILS

business: of Name 1.

name: Trading 2.

Limited Co. Partnership Sole trader 3.

Other Company Charity

Address: 4.
 number: Telephone 5.

Head office address: 6.

number: Telephone 7.

Name of person completing questionnaire: 8.

Your position / job title: 9.

i.e. main purpose of the business at the MAIN ACTIVITY Please describe the 10.

above named premises

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he number of employees at the premises at peak time? What is t 11. Workplace Health, Safety and
Welfare Workplace

Self employed female: Part-time female: Full-time female:

Priced publications (only available at HSE BOOKS)

Self employed male: Part-time male: Full-time male: Tel: 01787 881165 OR EMAIL:
www.hsebooks.gov.uk

Young employees/Trainees (16-18 yrs) ‘Management of Health and Safety at Work Regulations 1999
Approved Code of (1)

Practice and Guidance’

No Yes oyee/Trade Union Representative: Empl L21 (second edition) ISBN 0 7176 2488 9

No Yes Employers Liability Insurance: Code of ‘Workplace (Health, Safety and Welfare Regulations
1992, Approved (2)

Practice and Guidance’

work premises (including not employees visit your Do other persons who are 12. L24 ISBN 0 7176
04136

contractors or clients or members of the public)?

‘VDU’s: An Easy Guide to the Regulations’ HSG90 ISBN 0 7176 0735 06 (3)

No Yes

‘Health and Safety Law Poster’ ISBN 0 7176 2493 5 (4)

Addresses to be put on Health and Safety Law Poster

fety and controlled any hazards have you adequately assessed their sa YES If . 13
that may cause them injury?

No Yes ) Employment Medical Advisory Service (EMAS Enforcing Authority

Health and Safety Executive Weymouth & Portland Borough Council

ACCIDENTS Intercity House Environmental Health Unit

Mitchell Lane Council Offices

which accidents and dangerous occurrences are legally required Do you know 14. Victoria Street
North Quay

? F2508 to be reported to the Environmental Health Unit on Form Bristol Weymouth

BS1 6AN Dorset

No Yes DT4 8TA

Tel: 01179 886000

? accident record system Do you have an accident book or similar 15. Tel: 01305 838432

Fax: 01305 766684

No Yes

l similar accidents in 6 months; major accidents/ Significant entries (e.g. severa

incident?)

HSE Main Website: www.hse.gov.uk

HMSO website: www.legislation.hmso.gov.uk

Do you have a first aid kit? 16.

Other sites:

No Yes

www.nuneatonandbedworth.gov.uk/business/healthsafety

Are there any trained first aiders? 17.

No Yes

ed persons trained to seek medical help in an Are there one or more appoint 18.

emergency situation?

No Yes

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EXAMPLE LIST OF FREE HEALTH AND SAFETY LEAFLETS

Please tick the boxes of any that you would like us to send (see note). injury incident rate Please
calculate your companies 19.

RIDDOR Explained Accidents Step 1 – Calculate the total number of reportable injuries in the year

Step 2 - Times this number by 100,000

Managing Asbestos in Workplace Buildings Asbestos Step 3 - Divide the total by your number of
employees

Electrical Safety and You Electrical Reportable injuries x 100,000

rtable Electrical Equipment in Offices and Other Maintaining Po Number of employees

Low Risk Environments

NOTE: Reportable injuries (RIDDOR) include major injuries e.g. broken leg,
First Aid at Work – Your Questions Answered First Aid fractured skull and over 3 days off work
injuries or cannot carry out normal

duties due to injuries

Gas Appliances – Get Them Checked, Keep Them Safe Gas

FIRE PRECAUTIONS AND EMERGENCY EVACUATION

Be safe – The Costs of Accidents – A Guide for Small Firms General

Health and Safety at Work etc. Act 1974, Advice to Employers Health and about the action to be taken
on Have all relevant persons been trained 20.

and safety Safety a fire is given or any other discovering a fire or when a warning of

Managing Health and Safety – Five Steps to Success emergency situation?

Officewise

What to Expect When a Health and Safety Inspector Calls No Yes

COSHH – A Brief Guide to the Regulations Hazardous re extinguisher(s) at the premises? Do you
provide the correct portable fi 21.

Substances

No Yes

5 Steps to Risk Assessment Health and

Starting Your Business Safety ttled gases in your business? Do you use flammable liquids or bo 22.

Documentation

No Yes

erations and Lifting Equipment Simple Guide to the Lifting Op Lifting

Regulations 1998 Equipment If Yes, do you provide safe storage for them?

Getting to Grips with Manual Handling – A Short Guide for Manual No Yes

Employees Handling

IF YOU DO NOT EMPLOY ANYONE YOU ARE NOT REQUIRED TO FILL IN

‘Five Steps to Risk Assessment‘ INDG163 Risk THE REST OF THE QUESTIONNAIRE, SIMPLY RETURN
THE ABOVE

struction and Training’ INDG213 ‘Five Steps to Information, In Assessment INFORMATION IN THE
SAE PROVIDED.

‘Managing Health and Safety: Five Steps to Success’ INDG275

‘Starting Your Business – Guide on Preparing a Health and Slips and YOUR SAFETY POLICIES

Safety Policy document’ INDG324 Trips

‘Consulting Employees on Health and Safety – A Guide to the ? safety policy Has your business
produced a written company 23.

Law’ INDG232 (Not applicable if less than 5 employees at all company locations)

Help on Work Related Stress – A Short Guide Stress Not applicable No Yes

Violence at Work – A Guide for Employers Violence does it include:- Yes, If

Working with VDU’s VDU No Yes Statement of general policy

No Yes Organisation:

Simple Guide to the Provision and Use of Work Equipment Work No Yes Arrangements:

Regulations 1998 Equipment No Yes Signed and reviewed

Working Alone in Safety – Controlling the Risks of Solitary Work Working Alone Please state last
revision date:

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onal dditi e a di v pro sh to i w or make s to t n mme her co furt y an ev u ha oy If

: wo bel ils a the det ev gi ase on, ple ati m infor

ed i ises (i.e. identif m ssment at the pre out a risk asse rried ou ca y Have 24.

ed out the associated risk)? kr o w hazards and

Ne

?s ing d cant fin fi signi of all the d recor oduced a r ou p y If so, have 25.

(if less than 5 Not applicable No s eY

ll a t a seey emplo

snoit acol y compan

?sg ndin fi in a are the m What

yed or ’ Poster displa w ould Kno ou Sh Y w ‘What La y fet a Is a Health and S 26.

emises? at the pr d leaflets distribute

osY

Ne

ho visit other w one e.g. van drivers, staff l rk a o w o h y staff w have an ou y Do 27.

?ct e enol a snoit acol

Ne

edures in c y pro d emergenc ements an arrang rking o w he safe e t r hat a w , Yes fI

: workers place for these

SSMENT SE SA TED THE SELF MPLE CO W NO VE A U H O NK YOU, Y A TH

RE I A NN IO EST UQ

ges pa n nd o u fo n be ects ca j sub these e on bl aila v are a that lets f lea f st o li A

13. 12 and

) ge 13 pa bsite (see e w SE Books e H h sit t i v u can oy y el vit rna etl A

ion. t rma o e inf th evi e sh to rec i w u oy xes if bo nt av le e the r Please tick

4 11

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). ter a ins tap w a ill include m (This w ? ter a inking w ovide dr pr ou y Do 63. D NA NG NI I A N,
SUPERVISION, TR O CTI ION, INSTRU TA INFORM

ON I TATL CONSU

o N seY

?gni ni art nduction i yt health and safe eey Is there emplo 28.

t drink? o e for staff to make a h l Is it possib 64.

o N s Ye

No s Ye

aining r t y nd safet alth a fresher he e Do staff receive r 29.

rictions on smoking at work? t res y an Are there 65.

o N s Ye

No s Ye

concerns? y fet a heir health and s t ees about y plo m ou consult e y Do 30.

th seating? i w st area re r ide a smoke free staff room o vor you p do No, If o N seY

No s eY rmation, info y ng specific health and safet quiri satisfied that people re uoy Are 31.

nd consultation have received it? E.g. on a instruction, supervision, training

s to d nursing mother an men o w gnant provisions for pre ade ou m y Have 66 . y ner dangerous
machi

eed to? n y n if the lie dow

o N s Ye

No s Ye
y ealth and safet written h th other i w ees y ovided emplo r ou p y Have 32.

STRESS M

?no ati m Infor

rkplace? o w the ken a stress risk assessment in a ndert ou u y Have 67. No s eY

o N seY RDS AZ CE HA ALPKR WO

the premises? E.g. boiler, coffee ssurised appliances at have pre ou y Do 33.

? ssor e compr machine, air

work? mbat stress at een made to co ngements have b rra hat a w Yes, If

o N s Ye

a y essurised appliances maintained and tested b r p r you , are Yes fI

? y t yearl s at lea engineer) n (e.g. insurance competent perso

o N s Ye

e same area? th nd vehicles move around in Do pedestrians a 34.

el bacil ppa Not o N seY

similar? r o y ba Is there a loading 35.

o N s Ye

ents in place for rrangem a y , please explain the safet Yes fI

moving/unloading/reversing etc .

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Does the premises have an intermediate floor or high level storage area 36. HARMFUL SUBSTANCES

more than two metres off the ground which people must use?

as those labelled as toxic, Do you use or store harmful substances such 59.

No Yes quantities of domestic Harmful, irritant or corrosive? (Other than normal

materials) Cleaning

Are you satisfied that all dangerous parts of work equipment are 37.

adequately guarded? No Yes

Not applicable No Yes he harmful substances present at please give brief details of t Yes, If

es and whether they your premises, the amounts of these substanc

SH

r every Is lifting equipment thoroughly examined by a competent enginee 38. are only stored at the
premises or are in use by staff?

12 months? (6 months for passenger lifts)

Is personal How are they Where stored: Substances

There is no lifting equipment No Yes protective used:

equipment

WORKPLACE RISKS Required?

Are services such as mechanical ventilation systems in good repair and 39.

regularly maintained?

N s o Ye
ondition, free from holes, is even and not Is all the flooring in good c 40.

slippery? ASBESTOS

No Yes in the building, have you If there is a possibility that asbestos exists with 60.

carried out a survey to find out whether asbestos is present in the

Are all staircases to the premises well constructed with a 41. building?

handrail provided on at least one side?

Not applicable No Yes

Not applicable No Yes

, are maintenance personnel including contractors informed Yes If

and fire exits always kept free of obstructions Are staircases, walkways 42. of its presence and is any
work undertaken done in accordance

which could cause a person to trip or fall? with the Control of Asbestos at Work Regulations?

No Yes No Yes

Are all shelving and racking units well made and strong enough for the 43. WORKING TIME
REGULATIONS

loads placed on them?

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

No Yes

HH No Yes

Are you satisfied that your premises is provided with safe means of 44.

lly rated step-ladder or kick-stool? reaching heights such as a commercia WELFARE

No Yes How many toilets and non WC hand washing facilities are there? 61.
ied that windows or external doors higher than the ground Are you satisf 45. Non WC hand Unisex
Male Female

floor can be opened without danger? wash basins

Not applicable No Yes

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the workplace is kept clean? Are you satisfied that 54.

HR Do the workrooms have enough free space to allow people to move about 46.

No Yes with ease?

e is stored in suitable bins which are emptied Are you satisfied that all wast 55. No Yes

Regularly?

Do you have a safe system of work for window cleaning and other 47.

No Yes cleaning/maintenance tasks at high level?

all workstations (i.e. desks, benches, counters) and Are you satisfied that 56. Not applicable No
Yes

Seating are suitable for the people using them and for the work?

pment (any appliance fitted with a plug) Is your portable electrical equi 48.

No Yes regularly inspected and maintained?

Do any staff regularly use a computer continuously for at least 2 hours per day? 57. No Yes

N s o Ye how is the equipment checked? Yes, If

do you provide: Yes, If With our own PAT equipment By an electrician

No Yes

Suitable desks with enough room for all the equipment? Other Visual inspection only

Modern, fully adjustable 5-point chairs?

Enough room around each desk? how often is the equipment tested? Yes, If

Monitors with adjustable controls?

Suitable keyboards or mouse controls? the building regularly inspected and Is the fixed electrical
installation in 49.

Computer equipment which is adjustable in height, tilt and layout? maintained?

Free eye-tests with an optician?

Regular breaks for staff away from the screen? No Yes

or distracting reflections? Adequate lighting, free from glare

Information to staff about the problems of poor posture and fatigue? If Yes, how often?

MANUAL HANDLING Is all equipment used at work safe to use 50.

SR

Are there any people who must carry heavy goods or awkward items such as 58. No Yes

containers or items of work equipment? Stationery or stock deliveries, drink

N s o Ye WORKPLACE HEALTH
 what is/are the main manual handling tasks? Yes, If Are you satisfied that all workrooms are
adequately ventilated? 51.

No Yes

how are workrooms ventilated? Yes, If

Mechanical ventilation system Openable windows

Are you satisfied that the workroom temperature is comfortable? 52.

No Yes

fficient lighting to enable people to work and Are you satisfied that there is su 53.

move about safely?

No Yes

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