Safety Statement Template details Please complete the form below to provide us with the minimum amount of detail we will need to compile your Safety Statement. By its nature the form is somewhat generic, therefore please send additional information such as Logos, site specific information, or other information that you need in your Safety Statement to the email address at the top of this page. * indicates required fields    *Company name:   *Trading name:   *Address 1:   Address 2:   Address 3:   *Contact phone number:   *Managing director:   *Manager/employee who will look after H&S:   *Number of staff:   *Operating hours (average):   Industry sector:  Agriculture & Forestery  Chemical  Construction  Education  Fishing  General Industry  Hospitality   please select:  Manufacturing  Quarrying  Retail  Service Industry  Service Station  Transport  Other   If "other" please specify:   *General description of activities:   Known operating hazards:  Abrasive wheels  Access and egress  Battery charging  Bullying  Cash handling  Company vehicles  Compressors  Electricity  Ergonomics  Fire   please select:  Food preparation - machinery  Food Food Preparation - knives  Fork lift trucks  Fuel  Feulling  General assembly  Hazardous substances  Housekeeping  Ladders  Lifting operations   please select:  Machinery  Maintenance  Manual handling  Oxy/acetylene torch  Pallet trucks  Portable generators  Power tools  Production lines  Scaffolding  Slips & falls   please select:  Stress  Visual display units / PC  Welding & flame cutting  Working at height  Young persons  Other   If "other" please give details:   What departments do you have?:  Administration  Engineering facilities  Finance  Head office  Health & safety  Human resources  IT  Operations  Packhouse  Production areas   please select:  Quality assurance  Sales  Security  Stores  Transport  Warehouse  Workshop  Other  Other   If "other" please give details:   *Do you have a Safety Committee?: Yes No   If "yes" please supply commmittee member names:   *have your staff elected a safety representative?: Yes No   If "yes" please supply name(s):   *Do you have a formal staff communication method?: Yes No   If "yes" please give details:   *Do you have an existing safety statement?: Yes No   If "yes" should we use any information from it?: Yes No   If "yes" please give details & email a copy to us:   *Who should we contact with questions?:   *Please supply contact email:   *Please supply contact phone number: Please click on the Submit button to submit the form details.

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