Health and Safety Policy Appendices 2019 / 2020
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Health and Safety Policy
Appendices 2019 / 2020
The contents of this policy are based on the requirements of health and safety law and associated Health and Safety
Executive advice and Department for Education advice on legal duties and powers for local authorities, school leaders,
school staff and governing bodies
Health and Safety Policy Appendices 2019/2020 ContentsContents Contents 2 Appendix 1 – Categorization of Departments by risk.............................................................................................................. 3 Appendix 2 – Pupil accident report form ................................................................................................................................. 4 Appendix 3 – Staff accident report form ................................................................................................................................. 5 Appendix 4 – RBCS List of First Aiders .................................................................................................................................. 6 Appendix 5 – Contractor Safety Evaluation Questionnaire..................................................................................................... 7 Appendix 6 – RBCS Driver Declaration Form......................................................................................................................... 9 Appendix 7 – RBCS Risk Assessment form ......................................................................................................................... 11 Appendix 8 – Near Miss ........................................................................................................................................................ 12 Health and Safety Policy Appendices 2019/2020 Contents
Appendix 1 – Categorization of Departments by risk
Department Risk Department Risk
Activities High History Low
Administration Low Housekeeping High
Admissions & Marketing Low Human Resources Low
Art High Information Technology Low
Biology High IT Support Low
Bursary Low Learning Support Low
Catering Low Library Low
Car Parking High Maintenance High
CCF High Mathematics Low
Chemistry High Medical High
Classics/Latin Low Modern Languages Low
Cleaning Low Music Low
Design Technology High Network Manager Low
Development Low Physics High
DoE High Psychology Low
Drama High Reception Low
Economics & Business Low Religious Studies Low
English Low Rowing High
Examinations Low School House Low
Geography Low Sport and PE High
Geology Low Sports Facilities Manager (re lettings) High
Government and Politics Low Warden Low
Grounds High Wilderness High
Health and Safety Policy Appendices 2019/2020 Page 3Appendix 2 – Pupil accident report form
Pupil Accident Report Form
1 School Nurse (this area is to be completed by teacher/staff member if
completes incident occurs out of hours, e.g. Trips, or Saturday
fixures)
Date of report
Date of accident time:
Student Name Tutor:
Date of Birth
Nature of Injury
2 Member of Staff completes (Staff in charge or discovering)
Staff Name
Date of accident time:
Location
Activity + details of action taken by staff member:
Staff to email this completed form back to the Nurse within 48 hours.
3 Form returned to School Nurse
Entry of information by Nurse
Form emailed to: Bursar; Second Master date:
4 The Follow Up (to be completed by the Bursary if required)
Possible cause of accident and recommendations to prevent reoccurrence
Action taken(by whom & target date for completion)
Notifiable to HSE yes/no
Signature
Name (in blocks)
Position
Health and Safety Policy Appendices 2019/2020 Page 4Appendix 3 – Staff accident report form
Staff Accident Report Form
1 School Nurse (this area is to be completed by teacher/staff member if
completes incident occurs out of hours, e.g. Trips, or Saturday
fixures)
Date of report
Date of accident time:
Staff Name
Nature of Injury
2 Member of Staff completes (Staff in charge or discovering)
Staff Name
Date of time:
accident
Location
Activity + details of action taken by staff member:
Staff to email this completed form back to the Nurse within 48 hours.
3 Form returned to School Nurse
Entry of information by Nurse
Form emailed to: Bursar; Second Master date:
4 The Follow Up (to be completed by the Bursary if required)
Possible cause of accident and recommendations to prevent reoccurrence
Action taken(by whom & target date for completion)
Notifiable to HSE yes/no
Signature
Name (in
blocks)
Position
Health and Safety Policy Appendices 2019/2020 Page 5Appendix 4 – RBCS List of First Aiders
Full Name First Aid Full Name First Aid
expiry expiry
Mr M Baker 06/06/2021 Mr H McGough 01/10/2021
Mrs C Bamforth 06/07/2019 Mr R Meehan 29/08/2021
Mr S Bateman 06/06/2021 Mr R Mellows 07/06/2021
Miss K Bayliss 06/06/2021 Mrs G Mitchell 28/05/2019
Mr T Bellinger 04/07/2020 Mr W Mitchell 13/06/2020
Mr C Bond 05/06/2021 Mrs G Montgomery 07/02/2021
Mr J Bowler 06/06/2021 Mr G Morton 07/02/2021
Mr A Colville 13/06/2020 Mr W Nash- 07/06/2021
Wortham
Mr R Cook 07/02/2021 Mrs H Oliver 07/06/2021
Mr S Cook 20/02/2021 Dr B Pennington 13/06/2021
Mrs R Crossland 06/06/2021 Mr M Pink 08/06/2019
Mrs C Dance 03/07/2020 Miss G Plowman 08/06/2019
Mr J Dance 07/02/2021 Mr P Saunders 16/05/2022
Mrs A Dewar 06/06/2021 Mr D Selvester 07/06/2021
Mr J Elzinga 29/09/2019 Mr T Seward 19/06/2019
Mr R Ennis 18/10/2021 Mr R Shuttleworth 02/05/2020
Miss C Fagg 21/03/2019 Mr J Slack 08/06/2019
Mrs G Finucane 13/06/2020 Mr R Starr 08/06/2019
Mr A French 23/10/2021 Mr M Stewart 08/06/2019
Mr W Gilbertson 23/04/2020 Miss A Thomas 07/06/2021
Mr K Hartland 18/06/2019 Mr P Thomas 07/11/2021
Mrs S Head 08/06/2019 Mr R Tidbury 07/06/2021
Miss C Holliday 06/06/2021 Miss B Truman 07/06/2021
Mr P Hoy 31/10/2019 Miss T van der 25/05/2019
Werff
Mr M Jerstice 08/06/2019 Mr M Velchev 07/02/2021
Miss C Knight 20/01/2020 Mr W Voice 14/06/2019
Mr S Lambert 03/10/2021 Mr N Warde 31/08/2020
Dr S Langdon 26/04/2021 Mrs A West 22/08/2020
Mr J Leigh 07/06/2021 Mr M Wharton 06/11/2021
Mr T Liversage 23/10/2021 Mr E Whitehouse 09/01/2021
Mr A Maddocks 08/06/2019 Miss C Willis 18/07/2022
Dr K Magill 23/09/2021 Mr G Wilson 22/05/2021
Mr S McFaul 08/06/2019 Mr S Yates 14/06/2019
Mrs J Zambon 07/06/2021
Health and Safety Policy Appendices 2019/2020 Page 6Appendix 5 – Contractor Safety Evaluation Questionnaire Please complete the following sections and supply the relevant information as requested. 1 Company address and contact details 2 Please supply a chart showing your company health and safety organisation 3 Who in your organisation is ultimately responsible for health and safety? Name Position Contact Details 4 Who in your organisation is responsible for the management of health and safety? Name Position Contact Details Qualifications 5 Please supply a copy of your company’s safety policy arrangements/risk assessments relevant to the work for which you are tendering. 6 Supply details of relevant health and safety/professional/driver/operator training which has been provided to company personnel in the last 12 months (attach copies of certificates and competence certification) please use separate sheet if required Course Training Provider Dates 7 Does your company use sub-contractors? YES NO If YES please outline how you ensure the competence of them Health and Safety Policy Appendices 2019/2020 Page 7
8 Complete the following table with the number of accidents (include road traffic accidents) and dangerous
occurrences experienced by your company over the last 2 years.
Year Fatalities Major Accidents Dangerous Over 3 day lost time
Occurrences accidents
9 Complete the following table with the details of relevant enforcement notices issued and prosecutions over the
last two years (use separate sheet if required)
Year Notice Details Remedial Action
10 Supply details of relevant trade/professional associations to which your company belongs and accreditates
e.g. BAFE, UKAS accreditation
11 Supply contact details of two organisations that your company works for
Contact Name Contact Name
Address Address
Telephone Telephone
Fax Fax
Email Email
Nature of Nature of
Contract Contract
12 Supply evidence of the following insurances *
Expiry Date Expiry Date
Employer’s Liability Public Liability
Contractors All Risk Professional Indemnity
13 Questionnaire completed by
Name
Address
Position
Signature Date
*NB Required levels of insurance cover should be added by originator of form
Health and Safety Policy Appendices 2019/2020 Page 8Appendix 6 – RBCS Driver Declaration Form
1. Driver’s personal details
Surname Forename(s)
Date of birth Job title
National Insurance No. Home address
Have you had an insurance proposal declined, a policy
cancelled, been required to pay an additional premium YES/NO
or had special conditions imposed by a motor insurer?
2. Driver’s medical details for fitness to drive (you must refer to DVLA leaflet D100 – Driving Licences before
answering this section – www.direct.gov.uk/driving) See reverse for further info.
Do you have a DVLA notifiable If yes, have you reported the condition to
condition? YES/NO DVLA and have you received approval to YES/NO
drive with no restrictions?
Do you need to wear corrective If yes, have you had your eyesight
lenses/glasses for driving? YES/NO examined within the past 2 years? YES/NO
Do you take medicines or prescribed If yes, are you willing to take a medical
drugs that may induce drowsiness or YES/NO examination by a doctor to confirm your YES/NO
otherwise impair your driving? fitness to drive?
3. Driver’s licence details
Address (if different
from above) Groups /
Categories
Driver licence number
Valid From: To: Country of issue
Number of years you
Date driving test passed
have held full licence
4. Driver’s insurance details (if applicable)
Insurers Name Comprehensive/Third Party
Type of insurance
Policy Number
5. Details of any enforcement action (include any that are pending) and/or accidents in the last 3 years
Fine/penalty
Date Offence / Accident Offence code points/disqualification/pending
offence
I confirm that I have read, understand and will comply with the School Driver & Vehicle Operating Policy. I
confirm that the above information is a true and accurate record to the best of my knowledge at the time of
completing this form. I authorise the School to make any necessary investigations regarding my driving
history with the DVLA. I agree to inform the Bursar immediately if these details change.
Signed: Date:
Health and Safety Policy Appendices 2019/2020 Page 9Health and Safety Policy Appendices 2019/2020 Page 10
Appendix 7 – RBCS Risk Assessment form
Name of person completing Department
assessment
Title of activity / trip Date & time
Description of the activity /
trip
Location of the activity / trip
How might the harm occur Further action required to control Person Target date Completion
Risk controls – what is already in
i.e. what is the risk? and who might risk responsible date
place?
be harmed?
Signed off by Signed off date
Health and Safety Policy Appendices 2019/2020 Page 11Appendix 8 – Near Miss
A Near Miss is an event, a situation or an action that came close to causing an injury or property damage
Name
Date of near miss
Time of near miss
Describe the near miss Where did it happen?
Action taken to prevent it happening again Hazard removal? yes/no
Once completed send this card to your safety coordinator so that all appropriate people can be made aware,
corrective action can be taken and the near miss can be logged.
Health and Safety Policy Appendices 2019/2020 Page 12You can also read
