Lone Worker Risk Assessment & Method Statement

This form will help to identify if it is safe for you to work alone on customer sites. You must never work alone when
using high voltage electricity, working in confined spaces or working at height. If in doubt at any stage contact your
manager or site manager before starting works.

Job Welfare &

1 Arrival On-Site 2 3 Risk Assessment
First Aid

 Site safety induction & arrival on customer site

Please answer all questions in this form

 Your Company Name *

 Name of customer site you are visiting *
 Date of site visit *MM/DD/YYYY
 Your Name *FirstLast
 Your email address *
 Email copy to other person (optional)
 Email copy to other person (optional)
 Address of Site (where works are to commence)
Street AddressAddress Line 2CityState / Province / RegionPostal / Zip Code United
States United Kingdom Australia Canada France New Zealand India Brazil ---
- Afghanistan Åland Islands Albania Algeria American
Samoa Andorra Angola Anguilla Antarctica Antigua and
Barbuda Argentina Armenia Aruba Austria Azerbaijan Bahamas Bahrain Bangladesh Ba
rbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and
Herzegovina Botswana British Indian Ocean Territory Brunei
Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman
Islands Central African Republic Chad Chile China Colombia Comoros Democratic
Republic of the Congo Republic of the Congo Cook Islands Costa Rica Côte
d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican
Republic East Timor Ecuador Egypt El Salvador Equatorial
Guinea Eritrea Estonia Ethiopia Faroe
Islands Fiji Finland Gabon Gambia Georgia Germany Ghana Gibraltar Greece Grenada
Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong
Kong Hungary Iceland Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan K
azakhstan Kenya Kiribati North Korea South
Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Li
thuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta M
arshall
Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegr
o Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands
Antilles Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papu
a New Guinea Paraguay Peru Philippines Poland Portugal Puerto
Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and
the Grenadines Samoa San Marino Sao Tome and Principe Saudi
Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon
Islands Somalia South Africa Spain Sri
Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzani
 a Thailand Togo Tonga Trinidad and
Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab
Emirates United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican
City Venezuela Vietnam Virgin Islands, British Virgin Islands,
U.S. Yemen Zambia Zimbabwe Country

 GPS location co-ordinates (optional)

 Please provide the name of the Emergency Contact or Person in Charge (PIC) of the
site. *FirstLast
 Please Enter the SITE EMERGENCY Contact Number *
In the event of an emergency please use the (SITE EMERGENCY) number supplied. When off site dial the emergency
services i.e. 999 or 911

 Have you reported to reception and signed in *

YesNoNo Site Reception

 Does the person in charge of the site know you have arrived on site and is aware you
will be starting work? Have you been authroised to start works by your client?
YesNo

 Have you received site safety induction training specific to the site your are visiting?
YesNoNo site safety induction training available

 Start Time of Job / Task (not 24 hour clock) i.e 3 PM not 1500
hoursHH:MM:SS AM PM AM/PM
 Anticipated Completion Time of Job / Task (not 24 hour clock) i.e 5 PM not 1700
hoursHH:MM:SS AM PM AM/PM

Lone Worker Risk Assessment & Method Statement

This form will help to identify if it is safe for you to work alone on customer sites. You must never work alone when
using high voltage electricity, working in confined spaces or working at height. If in doubt at any stage contact your
manager or site manager before starting works.

Job Welfare &

1 Arrival On-Site 2 3 Risk Assessment
First Aid

 Job Method Statement

Please ensure this section is completed before starting works.

 Task or job to be completed *

 Tools & Equipment to be used to complete the job or task
110 volt battery hand held drillElectric disk, finishing or drum floor sandersElectric jig or
circular saw110 volt transformer from 240 volt supplyReduced volt extension lead 240v to
110vDisk cutters or grindersChain saw or brush cutter / strimmers or mowersLadders,
platforms or scaf towersNon powered hand toolsSharpes, knives, stanley blades or
cuttersSolvents, oil, grease or other substancesWelding or hot works equipmentOther please
specify
 Other Tools or Work Equipment Required. If (none) are required then write
"None" in the box below
 Personal Protective Equipment require to complete the Job / Task (PPE) *
Protective GlovesProtective OverallsSafety glasses, goggles or visorsHead protecion or hard
hatHearing protection or ear defendersSafety boots, shoes or toe-tectorsRespiratory protective
masks or filtersHigh Viz clothingPersonal alarms or detectorsOther please specify

 PPE Other please specify. If no additional PPE is required write none in the
comments box below.

 Personal Welfare & Emergency First Aid Response

It is vital that before working alone on any site you consider how to raise the alarm in the event of an emergency. Please
complete the checklist below to help identify the risks involved when working alone and if it is safe to work alone. If in
doubt contact your manager and DO NOT START WORK.

 Please tick which of the following welfare facilities are available?

Fresh drinking waterToiletsWashing facilitiesEating facilites

 Is a trained and qualified first aider or first response team on site and aware
you are working alone?
YesNoN/A

 How will you raise the alarm in the event of an accident?

Site supervisor is present and will raise alarmUse a mobile phone or radioUse a personal
alarm

 How long will it take for the first response team to reach you in the event of
an emergency? If 5 minutes+ selected than alternative arrangements must be
considered.
Within 2 minutes2 - 5 minutes (with supervision & first aiders)5 - 10 minutes (unacceptable
risk to life)

Lone Worker Risk Assessment & Method Statement

This form will help to identify if it is safe for you to work alone on customer sites. You must never work alone when
using high voltage electricity, working in confined spaces or working at height. If in doubt at any stage contact your
manager or site manager before starting works.

Job Welfare &

1 Arrival On-Site 2 3 Risk Assessment
First Aid

 Risk Assessment Form ( Use the guidlines below to assess the risk rating)
Not Applicable = No risk present
Acceptable = No action required
Adequate = Look to improve at the next review
Tolerable = Look to improve within specified time or before work starts
Unacceptable = Do not start work and make immediate improvement

Please rate the risk of injury from the hazards identified whilst on site. If you identify
any unacceptable risks then please notify your manager or site manager and do not
commence works until the risks have been controlled or reduced to tolerable or
below. *

Not
Acceptable Adequate Tolerable Unacceptable
Applicable

Moving Plant
1 2 3 4 5
Traffic

Electric shock
or 1 2 3 4 5
electricution

Hand arm
virbration 1 2 3 4 5
exposure

falling object
1 2 3 4 5
or debris

Confined
1 2 3 4 5
space working

Slip, trip and

1 2 3 4 5
falls

Manual
1 2 3 4 5
Handling

Crush injuries 1 2 3 4 5

Hot works
burns, fumes 1 2 3 4 5
or arch eye

Drowning or
1 2 3 4 5
flooding

Sharps, cut or
1 2 3 4 5
skin puntures
 Please rate the risk of injury from the hazards identified whilst on site. If you identify
any unacceptable risks then please notify your manager or site manager and do not
commence works until the risks have been controlled or reduced to tolerable or
below. *

Not
Acceptable Adequate Tolerable Unacceptable
Applicable

Exposure to
noise 80 Dba 1 2 3 4 5
or above

Work at
height - fall 1 2 3 4 5
injuries

Verbal,
physical abuse 1 2 3 4 5
or attack

Explosive
atmoshperes 1 2 3 4 5
or risk of fire

Harm from
fumes, dust or
1 2 3 4 5
toxic
substances

pressure
systems or 1 2 3 4 5
hydrolic hoses

Contamination
or infection
1 2 3 4 5
via inhalation
or skin

 What control measures have been put in place (If Applicable)

 Upload a photo or file to support your risk assessment using your mobile
phone.
 Date Risk Assessment completedMM/DD/YYYY
 Please help us to improve this app by rating it.
 Please provide any feedback to help improve this form. Thank you!