Workplace Health and Safety Assessment Form

Employer / Location Health and Safety Assessment Record
For WBL and Work Experience Programmes
For work experience employers only (WBL employers go to employer

details)
Curriculum Team
Requested by
Placement Start
date
Placement End
date
Learners under 18
Yes/No
Multi site
working Yes/No
Health & Safety assessors to complete pages 1 to 6 for each employer and page 7
(standard 10) for each learner.
Employer Details:
Employers name:
Number of
employees:
Nature of business:
Workplace address:
Main contact:
(Name & Tel
No)
Health and
safety contact:
Learner(s) name(s):
Supervisor(s)
name(s):
Type of work carried
out at workplace
location:
Any Enforcement
action:
(Prosecutions,
Notices)
Yes / No
Employer Liability
Insurance
Health and safety

committee / safety
representation: Yes /
No
Insurer
Policy No
Expiry date
Workplace H&S assessment form

April 2011 Review April 2013
HL Wheatcroft
Page 1 of 9

Health and Safety Procurement Standard 1:
1
Health and Safety Policy
Is there a written H&S policy statement

mandatory when 5 or more employees)?
Does the policy have an organisation
section detailing the responsibilities for
health and safety (recorded when 5 or more
employees)?
Are arrangements for health and safety
clearly stated (recorded when 5 or more
employees)?
How is the policy communicated to
employees?
Assessment of Standard 1:
C
D
Risk assessment and control
Have risk assessments been carried out and

significant risks identified?
Have the significant findings and details of
any groups identified as being especially at
risk been recorded (mandatory where 5 or
more employees)?
Have control measures been identified and
put in place as a result of the risk
assessments?
Do the risk assessments take into account
young persons, including giving
consideration to their age, inexperience,
immaturity and lack of awareness of risks?
Give details of the risks and control
measures relating to the occupations and
the specific activities carried out in the
workplace.
How are the risks and control measures
explained to employees and others?
C
D
F
G
Yes/N
o
Met
Yes/N
o
Met
Accident, incidents and first aid
Yes/N
o
Have adequate arrangements for first aid

materials been made?
Have adequate arrangements for trained
first aid persons been made?
Are accidents and first aid treatment
rendered recorded?
Are or will all legally reportable accidents,
incidents and ill-health be reported to the
enforcing authority and to Loughborough
College and will they be investigated?
How are the arrangements for accidents,
incidents, ill-health and first aid made
known to all employees?
C
D
Part met
Not met
Evidence / comments
Are risk assessments reviewed eg. In light of

the findings from monitoring activities?
Evidence / comments

HL Wheatcroft
Met
Page 2 of 9
Part met
Not met
Evidence / comments
Part met
Not met

4
A
B
C
Supervision, training, information and

instruction
Are employees provided with adequate
competent supervision? (Note: where
necessary, suitability checks may be
required for reasons of child protection and
the protection of vulnerable adults)
Is health and safety information, instruction

and training recorded?
How is the effectiveness of health and

safety information, instruction and training
assessed, and is the assessment recorded?
Work equipment and machinery
Is correct machinery and equipment

provided to the appropriate standards?
Is equipment adequately maintained?
Are guards and control measures in place as

determined through risk assessment?
Are safe electrical systems and equipment

provided and maintained?
Personal protective equipment and

clothing
Is PPE/C provided, free of charge, to
employees as determined through risk
assessment?
Is training and information on the safe use

of PPE/C provided to all employees?
Is the proper use and storage of PPE/C

enforced?
Is PPE/C maintained and replaced?
Fire and emergencies
A
B
C
D
Evidence / comments
Supervisors name/s
Is initial health and safety information,

instruction and training given to all new
employees on recruitment?
Is ongoing health and safety information,
instruction and training provided to all
employees?
Yes/N
o
Met
Yes/N
o
Met
Part met
Evidence / comments
Met
Yes/N
o
Part met
Evidence / comments
Page 3 of 9
Not met
Evidence / comments
Yes/N
o
Is there a means of raising the alarm and

fire detection in place?
Are there appropriate means of fighting fire
in place?
Are effective means of escape in place
including unobstructed routes and exits?
Is there a named person(s) for
emergencies?

HL Wheatcroft
Part met
Not met
Not met

E
Is fire-fighting equipment, preventive

measures and emergency arrangements
maintained, including through tests and
practise drills?
Is a fire log/record book kept?

HL Wheatcroft
Met
Page 4 of 9
Part met
Not met

8
Safe and healthy working environment
Are premises (structure, fabric, fixtures and

fittings) safe and healthy (suitable,
maintained and kept clean)?
Is the working environment (temperature,

lighting, space, ventilation, noise) an
appropriate safe and healthy one?
Are welfare facilities (toilets, washing,

drinking, eating, changing) provided as
appropriate and maintained?
How is exposure to hazards from physical,

chemical and biological agents adequatrly
controlled?
9
A
B
C
D
E
F
G
H
General health and safety

management
How does the employer consult and
communicate with employees and allow
them to participate in health and safety?
Yes/N
o
Evidence / comments
Met
Part met
Yes/No
Not met
Evidence / comments
Does the employer provide medical /

health screening as appropriate and any
required medical / health surveillance?
Does the employer have access to
competent health and safety advice and
assistance?
Does the employer review health and
safety annually?
Does the employer display the necessary
signs and notices?
Has an OSR1 / F9 been completed and
sent to the enforcing authority?
Is employers liability insurance current
and other insurance in place as
appropriate to the business undertaking?
How does the employer assess, review
and update employees capabilities?
Insurer informed of learners? YES / NO / N/A
Working on other persons premises

I
Will the learner / apprentice be working
on sites other than those controled by the
employer
J
If the other persons premises are
domestic, how will you manage the H&S
K
L
If the other persons premises are

commercial and at multiple locations how
will you manage the employers H&
If the premises are commercial and your
employer is on placement or fixed term
how will you manage the H&S

HL Wheatcroft
Met
Page 5 of 9
Part met
Not met

Action Plan
Ref
Action required

HL Wheatcroft
Page
By who
Page 6 of 9
Target
date
Completed
(signed of)
of

Assessment Outcome:
Recommendation:
Accept
Risk Band
Organisational
Risk
Level
Risk category:
Low
Medium
High
Accept with action plan
Reject
Highest Occupational Risk Level

Low
Medium
High
Low
Low
Medium
Low
Medium
High
Unsatisfactory until Improvements Made
High
Medium
Low
The Employer or their representative:
(Please sign to agree that this is an accurate record of the assessment and action plan)
Print name:
Signature
Job title
Date:
Loughborough College representative

Assessment and action plan undertaken by:
Print name:
Signature
Job title
Date:
H&S qualification
Quality assured by:

Name:
Job title:
Date:
Other (please specify):
Date of next
assessment:
Assessment type:
Initial assessment
Re-assessment
Standard 10
HL Wheatcroft
Page 7 of 9

Learners name:
Employers name and
learners work
location(s):
1
0
A
B
C
D
Management of learners / young

persons /vulnerable adults health
and safety
Type of placement - employed status
(apprenticeship, TtG) work experience
Main occupation of the organisation
Area and type of work the learner /
apprentice will be occupied in
Age group
Yes/N
o
Evidence / comments
Pre 16
16-18
19-24
25+
Is the learner / apprentice classified as

vulnerable by age or other disclosure?
If the answer to E is yes complete the following:
F
Disclosures: (give details of any disclosures
that are relevant to their safety whilst at
work)
G
H
Summary of agreed tasks (refer to other

documents where applicable)
Has the employer assessed the risks to the
learner / young person taking into account
their age, inexperience, immaturity and
lack of awareness of risks?
Have the assessments taken into account
any other special needs or circumstances
including any learning difficulty, disability
and/or medical/health condition?
Has the employer put in place control
measures for learner / young person as a
result of the assessments and have they
informed the learner and their
supervisor(s)?
Detail any necessary prohibitions and
restrictions identified by the risk
assessments that apply to the
learner/young person.
Met
Part met
Action Plan
Ref
Action required
By who
Action
Date
Page
of
Completed
(signed of)
Plan
Prepared by:
Signe
d
Agreed by:
Signe

HL Wheatcroft
Target
date
Not met
Page 8 of 9

d
Review
dates:

HL Wheatcroft
Page 9 of 9

Workplace Health and Safety Assessment Form

Uploaded by

Copyright:

Available Formats

Workplace Health and Safety Assessment Form

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Workplace Health and Safety Assessment Form

Uploaded by

Copyright:

Available Formats

What is the purpose of this document?

What is the purpose of this document?

What health and safety standards are assessed?

What health and safety standards are assessed?

Employer / Location Health and Safety Assessment Record

For WBL and Work Experience Programmes

For work experience employers only (WBL employers go to employer

Health and safety

Workplace H&S assessment form

Employer / Location Health and Safety Assessment Record

Health and Safety Policy

Is there a written H&S policy statement

Risk assessment and control

Have risk assessments been carried out and

Accident, incidents and first aid

Have adequate arrangements for first aid

Are risk assessments reviewed eg. In light of

Workplace H&S assessment form

Employer / Location Health and Safety Assessment Record

Supervision, training, information and

Is health and safety information, instruction

How is the effectiveness of health and

Work equipment and machinery

Is correct machinery and equipment

Is equipment adequately maintained?

Are guards and control measures in place as

Are safe electrical systems and equipment

Personal protective equipment and

Is training and information on the safe use

Is the proper use and storage of PPE/C

Is PPE/C maintained and replaced?

Is initial health and safety information,

Is there a means of raising the alarm and

Workplace H&S assessment form

Employer / Location Health and Safety Assessment Record

Is fire-fighting equipment, preventive

Workplace H&S assessment form

Employer / Location Health and Safety Assessment Record

Safe and healthy working environment

Are premises (structure, fabric, fixtures and

Is the working environment (temperature,

Are welfare facilities (toilets, washing,

How is exposure to hazards from physical,

General health and safety

Does the employer provide medical /

Insurer informed of learners? YES / NO / N/A

Working on other persons premises

If the other persons premises are

Workplace H&S assessment form

Employer / Location Health and Safety Assessment Record

Workplace H&S assessment form

Employer / Location Health and Safety Assessment Record

Accept with action plan

Highest Occupational Risk Level

The Employer or their representative:

Loughborough College representative

Quality assured by:

Other (please specify):

Employer / Location Health and Safety Assessment Record