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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Phone (if different from above)

(###)

###

####

Person with overall responsibility for Health & Safety *

Same as main contact/lead person

Other

First Name

Last Name

Phone

(###)

###

####

Person with day to day responsibility for Health & Safety *

Same as above

Other

First Name

Last Name

Phone

(###)

###

####

Do you have an appointed internal or external Health & Safety Advisor? *

Yes

No

Name of appointed advisor

First Name

Last Name

Phone

(###)

###

####

Do you have an appointed First Aider?

Yes

No

Name of appointed First Aider

First Name

Last Name

Phone

(###)

###

####

Have you had any HSE Prohibition, FFI or Improvement Notices within the last 3 years? *

Yes

No

Have you had any RIDDOR incidents within the last three years? *

Yes

No

Do you have any of the following insurance cover?

Public Liability

Product Liability

Employers' Liability

Plant Insurance

Contracts Insurance

Other (please give details)

Are there any court actions and/or tribunal hearings outstanding against your Company? *

Yes

No

Is your company bankrupt or being wound up? *

Yes

No

Are your company affairs being administered by the court? *

Yes

No

Has your company entered any arrangement with creditors? *

Yes

No

Has your company ever been convicted of an offence concerning its professional conduct? *

Yes

No

Please tick below the training and/or qualifications your foremen/operatives have. This is to ensure all personnel has suitable skills for the activities assigned to them, unless there are specific situations where they need to work under competent control and/or supervision.

SMSTS

SSSTS

CPCS or equivalent Plant Operators Card

CISRS, Gas Safe, IPAF, SKILLcard, Other

NVQ, C&G or Certificates

Asbestos Awareness

Working at Height

First Aid at Work

Fire Training

Trade or Skill

Any other health and safety related training

Please confirm that relevant operatives hold a current CSCS Card

Yes

No

Please confirm the date your operatives last received Health and Safety training.

MM

DD

YYYY

Do you use subcontractors on any projects?

Yes

No

Please tick the accreditations you have:

SSIP

CHAS

SMAS

Name of person completing this form

First Name

Last Name

I confirm that all personnel associated with our Company are fully conversant and compliant with the requirements of CDM2015 and that all information given in this assessment is correct. *

By submitting your information through this form, you agree to Harrity Building and Construction Ltd storing and processing your personal data in accordance with our Privacy Policy (see website). This policy explains how we use your data, your rights under data protection law, and how to contact us about your information. You can withdraw your consent at any time.

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