Initial Site Assessment Form.

Site / Project Details:

Assessment Manager Name: Site Address: Client Name: Scope of Works: (include material type and locations) Client Contact Details: Assessment Date:

Site / Project Risk Assessment: On-Site Hazards

Asbestos Containing Materials? Damaged? Sealed / Encapsulated? ACM Fixings? Occupied Premises public exposure? DCU Connected? Transit route? Work at Height? Electricity Hazards i.e. lights? Confined Spaces i.e. ducts/basements? Lone Working Required? Hot Works? Extreme Temperatures? Works require Injection Methods? Works require Power Tools? Works near Glass materials? Works near Sharps / Needles. Site / Road Traffic? Biological Hazards i.e. Weils disease from Rat Urine or Pigeon Guano. Chemicals or Compressed Gasses Surrounding Work Area. Other:

Present (Yes/No)

Details:

Risk A B C

A Hazard Severity (1 5)
0 1: Low danger 2 3: Medium 4 5: High & Catastrophic

B Likelihood of occurrence (1 5)
0 1: Very Unlikely 2 3: Circumstantially Likely 4 5: Inevitable

C - Risk Assessment A+B (1 25)

1 10: Low Risk 11 16: Medium Risk 17 25: Highly Dangerous

Risk Notes: Where Medium and High risks are identified on this site risk assessment, control measures must
be implemented by management to reduce both the severity and likelihood, thus reducing the overall risk, prior to works commencement.

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Asbestos Removal Site Checklist: (Take Photos where applicable to include in Method Statement) ( Tick when assessed)
Access Arrangements Parking Facilities Skip Location DCU Location Power Source - Works Power Supply - DCU Water Supply - DCU Drainage - DCU Transit Route Waste Route Welfare facilities ACM Quantity Site Floor Plans Building Integrity i.e. damp / voids / holes? Site Survey Site Boundary Site Security Smoking Area

Determining Notification Requirements:

1. 2. Will works with AIB last longer than 1 hour a week? Is the ACM degraded or will works degrade the ACM? Yes / No Yes / No

In compliance with CAR 2012, if works with AIB will not last longer than 1 hour per week and will not degrade the ACM (or the ACM is not already degraded), then works can be carried out under short duration and non-continuous working methods and are not deemed Notifiable under the HSE Licensing Framework.

Licensing and Notification Matrix:

The works have been assessed and match the criteria of the following regulatory category: ( tick to confirm). Licensable & Notifiable Works Non Licensed & Notifiable Works Non Licensed & Non Notifiable Works Non Asbestos Works

Site Plan Enclosure Diagram:

(See page overleaf)

Additional Comments: (i.e. start dates etc)

Manager To Confirm This Assessment Is Correct As Of Date Of This Assessment:

Manager Sign to confirm: Date:

Further Action: (i.e. Provide Quotation, Prepare Method Statement & Risk Assessments, Project Notification)

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Site Plan Enclosure Diagram:

Diagram Key:

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