Business entity name

Business address

Name of premises

Number of employees

Owners name

Owner's contact number

Health & Safety Manager's name

Health & Safety Manager's number

HR Manager's name

HR Manager's number

Health & Safety Representative's name

Health & Safety Representative's number

Name of First Aider

Assembly point for evacuations

Does the premises have any of the following non-standard hazards? Does the premises have any of the following non-standard hazards? Bulk Boiling Pan Deep Fat Fryer Goods Lift / Dumb Waiter Mincer Slicer / Shredder Steaming Oven

Are there any other unusual hazards? Example: Spiral staircase