Health and Safety form

Please complete this form as best you can to help us work safely on your premises. Thank you.


YOUR DETAILS (required)

Customer Name

Your Email

SITE SAFETY (required)

Is there a Health and Safety Law poster on site?

YesNoDon't know

Health and Safety Law Poster location:

Are you satisfied the site has no unavoidable trip hazards and that access and movement around the site is unobstructed?

YesNoDon't know

Are stairways, fire escapes and high level openings provided with suitable handrails and guarding?

YesNoDon't know


Is there a First Aid box on site?

YesNoDon't know

First Aid box location:

In the event of an accident, Green Mop has its own accident reporting procedures. If you have your own accident reporting process for site visitors or contractors, please give the name and email address of the person responsible.

Accident reporting - name and email address:


Are periodic checks and tests undertaken on electrical and gas installations by a competent person?

YesNoDon't know

Are electrical safety checks made on portable appliances?

YesNoDon't know

ASBESTOS (required)

The Control of Asbestos at Work Regulations 2006 require the management of asbestos in non-domestic premises appropriate action regarding faults found.

Are arrangements in place to monitor and review asbestos or asbestos containing materials?

YesNoDon't know

Is any asbestos or asbestos containing material present at your premises?

YesNoDon't know

If asbestos is present at your site, please give details:

FIRE SAFETY (required)

Is there an out of hours emergency procedure for raising the alarm and evacuation?

YesNoDon't know

Location of your emergency fire procedures: