South Derbyshire District Council

When deciding where we need to visit, It would be helpful if you could let us know where your business is and what sort of health and safety systems you have in place. This short questionnaire will help us to assess whether you need any further advice or other inputs. We may have written to you asking for this data, in which case, filling in the form should reduce the need for us to visit you in the future. It would be helpful if the felds marked with a * could be filled in.

Please correct the information in the fields highlighted below.

Section 1 - You and Your Organisation

The reference number we have given you *

* Are you aware of your Health and Safety enforcing Authority?

If yes:

Please state LA or HSE

Name of inspector or contact at the Authority

Approximate date of last inspection

Contact Details

* Name of your organisation

* Road or street

* Town or Village

Postal Town (this will not apply to all addresses)

* County

* Post code

* Telephone

* Email address

* Web site

Registered Office if different from above

Company name

Road or street

Town or Village

Postal Town (this will not apply to all addresses)

County

Post code

Telephone

Email address

Web site

* Nature of the business:

If other, please describe

* Total number of employees including full-time and part-time staff:

Health and Safety Information

For further information please see www.hse.gov.uk/business/policy.htm

Do you have a written health and safety policy?:

Who is responsible for health and safety in your office?

Do you receive professional advice about health and safety ie. consultants, head office safety officer?:

If Yes or Other, please state who

Section 4 - Gas Safety (Installation and Use) Regulations 1998

For more information please see www.gassaferegister.co.uk

Has a gas safety check been carried out by a competent person in the last 12 months?:

If Yes, please enter details of engineer and date of gas safety check

Asbestos Management

For further information please see www.hse.gov.uk/asbestos

In which year approximately were the premises built?

Have you determined whether there is asbestos in the premises?:

If Yes, what action have you taken?

If No, do you have plans to carry out an asbestos risk assessment or survey?:

If so, what plans and when?

Thank you for taking the time to complete this questionnaire

Your risk score and future inspection dates (if necessary) will be determined by the answers that you have given.

Any other comments

Further information

Please Tel 01283 595944 or Email Commercial team

If you experience any problems with this form please contact econtent@derbyshire.gov.uk and quote form ID: ILF/153

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