An example of a risk assessment form by a9342032

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									                     SECTION 11 APPENDICES



           An example of a risk assessment form

            SUNNYDALE CLOSE RESIDENTS GROUP

           Friday 19th April 2004 10.30am to 12.30pm
                          LITTER PICK

OVERVIEW
Sunnydale Close has become more untidy and there have been
complaints about litter, abandoned furniture and generally how
neglected the place looks. The residents group have decided to
organise a litter pick and clean up day during the Easter holidays.
The DCHA Housing Officer has agreed to pay for the hire of a skip
to put old furniture and rubbish in and donate a £50 B&Q voucher
to pay for protective gloves and strong garden refuse bags.

RISKS: the residents‟ group want to encourage the children to take
part to promote the importance of keeping the close tidy but are
also aware of some of the potential hazards of involving children in
picking up rubbish: glass, dog excrement, needles. The Sunnydale
Close is fortunate that no needles have been found abandoned in
the past. If your estate or road is not so fortunate you would be
advised to talk with your Housing Officer and Environmental Health
Department before organising a litter pick. They will be able to
work with you to ensure there is someone there with the
equipment (sharps box) and knowledge to collect and dispose of
any found needles safely.


Activity                        Risk
                                (HIGH,      RESPONSE/Remedy
                                MEDIUM
                                OR LOW)
Litter pick to include children Medium      All those involved in the litter
                                            pick will be given protective
                                            gloves, strong plastic garden bin
                                            bags, trowels and asked to wear
                                            old and sensible clothes.
                                            Everyone will gather at the
                                            beginning of the „pick‟ and strict
                                            instructions will be given:
                       SECTION 11 APPENDICES


                                          Children will be accompanied by
                                          a parent/carer and must not pick
                                          up:
                                              broken glass
                                              sharp metal
                                              medicines (pills, syringes)
                                              dog or cat excrement

Accidents                      Low        The first aid kit and nominated
Liz and Mark‟s                            first Aiders, Mark and Liz Rawd
mobile contact Tel no                     will be positioned outside their
078643218070                              house (No3) next to the Skip,
                                          they can be contacted by mobile,
                                          children will be alerted to not
                                          picking up sharp/unsafe items,
                                          gloves are being worn.
Setting fire to the skip       low        The skip is being placed in the
                                          driveway of No 3. No 3 has
                                          security lights
Non Close residents using      low        The skip is being delivered on
the skip                                  Friday morning at 9am and
                                          picked up Saturday at 10am. As
                                          above, the position of skip is in
                                          the drive of no 3 who have
                                          security lights. We will cover the
                                          skip with a tarpaulin over night.
Poor behaviour                 low        The residents have volunteered
                                          to attend, children are
                                          accompanied by their parents,
                                          and are well motivated and
                                          monitored.
Personal hygiene               low        Everyone is advised not to eat
                                          snacks while collecting the
                                          rubbish and wash their hands
                                          afterwards.
                         SECTION 11 APPENDICES



    INFLATABLE BOUNCING DEVICES CONDITIONS

In connection with the operation, use, storage and maintenance of inflatable
bouncing devices it is a condition precedent to liability that:

   i. The Device is:

          a) Property anchored with Manufacturers/Hirers instructions.

          b) Only used in accordance with Manufacturers/Hirers instructions.

          c) Stored and maintained as per Manufacturers/Hirers instructions.

   ii. When used on hard surfaces, “gym” type mats are placed across the
       front of the Device.

   iii. All engines and compressor units are fully guarded.

  iv. All electricity cables are fully protected from damage or water.

   v. The Device is supervised at all times by a responsible adult.

  vi. The Insured that at all times children on the Device.

          a) Are not overcrowded.

          b) Are not under five years of age or over fourteen years of age.

          c) Are not pushing or colliding with one another.

          d) Have removed their shoes.

          e) Are not eating, drinking or chewing.

          f) Are not climbing or sitting on walls.

  vii. An area of two metres wide around the front of the Device is kept
       completely clear.

 viii. The Device is not to be used in the rain or if it otherwise becomes wet.
                             SECTION 11 APPENDICES



                    EMERGENCY INFORMATION

Location of the nearest telephone       …………………………………………..

Telephone number                        …………………………………………..

Useful telephone numbers:

      NHS Direct                       …………………………………………..

      Local Hospital                   …………………………………………..

      Nearest Doctors Surgery          …………………………………………..

      Taxi Firm                        …………………………………………..

      Social Services Dept Duty        …………………………………………..
       Officer

Location of the following:

      First Aid Box                    …………………………………………..
      Water/gas/electricity turn off
       points                           …………………………………………..

      Nearest A & E Dept               …………………………………………..

First Aider(s)


Date filled in:




N.B: Ensure this information can be accessed easily
and quickly.
                             SECTION 11 APPENDICES



                         ACTIVITY ATTENDANCE FORM

COMMUNITY GROUPS NAME:

EVENT:                                                         DATE:
                                                                          RELEVANT
                                                               CONTACT
                   DATE OF                           NEXT OF               MEDICAL
FORENAME SURNAME                 ADDRESS                        PHONE
                    BIRTH                              KIN               INFORMATIO
                                                               NUMBER
                                                                              N
                         SECTION 11 APPENDICES

                CHILD PROTECTION STATEMENT

Name of group:




Child Protection covering statement
The ****************** group takes seriously its responsibility to protect
and safeguard the welfare of children and young people entrusted to its
care. It recognises that children and young people including those from
minority ethnic communities, or those who are disabled, are particularly
vulnerable to abuse. It also recognises its limitations and will ensure that
it will only organise and plan children‟s or young people‟s activities with
the full support and involvement of the children‟s parents and with advice
and involvement from professional service providers like: play and
children‟s groups, the youth service, schools, connexions and social
services.

The residents group will ensure:

             that all committee members are aware of the importance
              of implementing child protection procedures and
              understand that abuse can happen in different ways
              including:
               physical abuse
               sexual abuse
               emotional abuse
             that if there is a concern that abuse is taking place that the
              person with that concern will contact the Duty Officer at
              their local Social Services office. (add telephone number)
             All children aged under 16 years taking part in off estate
              activities will be accompanied by a parent/carer. 16/17
              year olds living at home must have permission from their
              parent/carer to take part in off-estate activities.
             all workshop leaders or children‟s‟ entertainers employed
              by the group will have to produce evidence to prove they
              have public liability insurance and have been police
              checked. If they have not been police checked they must
              not be left alone with children or young people.
             all non-police checked volunteers working with children
              are never left unsupervised
                        SECTION 11 APPENDICES
            when organising activities like after school and summer
             holiday clubs all volunteer workers are police checked and
             professional advice is sought from a children‟s‟ or play
             specialist organisation.
            risk assessment forms are completed for every activity
             involving children and young people
            incidents and accidents are recorded and a copy given to
             the child‟s parent/carer
            that a safe ratio of adults to children is maintained at all
             times Adults : Children
                       0 to 2 years              1:3
                       2 to 3 years           1:4
                      3 to 8 years             1:8
            that there is always 2 adults present at all times when
             supervising activities on the estate and that where
             possible those adults are police checked.

This statement was agreed on (add date) and will reviewed on a 12
monthly basis next review due on (add date)

Signature (the Chair of the group)

Date:

Witnessed by: (another member of the Committee)
                                 SECTION 11 APPENDICES


                                    CONSENT FORM
DCHA advise that where possible parent/carers accompany their children aged 16
years or under on all resident group organised events. This form can be used for 16
to 18 year olds and younger children if the community group feel confident they can
cover the health and safety of younger unaccompanied residents.
Name of Residents’/Community Group:

Dear Parent/Guardian,
Please complete and return the form below that relates to the
forthcoming journey or activity for which you have already received
details. The form gives your consent for your child to take part in this
activity.

Details of event:

Venue:

From:                                              To:

I agree to my son/daughter taking part in the above mentioned event.

Name of child:                                     Date of birth:

Home Address:




Postcode:

Parent/Guardian Telephone Number (Home)            Parent/Guardian Telephone Number (Work)



Medical Information

Name of Doctor:

Doctor’s address:




Special details: Any relevant information concerning your child‟s health requiring special
attention but which does not prevent him/her taking part should be noted below. For example
does your child:
     Have any allergies?
     Experience travel sickness?
     Have diabetes, asthma or epilepsy?
                                      SECTION 11 APPENDICES

Is your son/daughter allergic to any medication? If yes, please give details below:




Has your child had any relevant recent illness?

Does your son/daughter have any special dietary requirements? If yes, please give details below:




Has your son/daughter received a tetanus injection                                    YES     NO

I undertake to inform the residents’ group as soon as possible of any change in the medical
circumstances between the date signed and the commencement of the residential trip.

Can your child swim at least 50 metres? (only applicable for water activities)        YES     NO

We would appreciate an alternative contact name and details (in case of an emergency)

Name:

Relationship to child (e.g. aunt/grandparent/neighbour):

Address:




Contact telephone number:

Any other comments or information you feel may be useful:




    1. I would like my son/daughter to take part in the above mentioned visit or activity and having
       read the information provided agree to him/her taking part in the activities described.
    2. I consent to any emergency medical treatment required by my child during the course of the
       visit.
    3. I confirm that my child is in good health and I consider him/her fit to participate.

________________________                                       _______________

Signature of Parent/Guardian                                            Date




This form should be returned to ………………………….. no later than………………………… If
you have any questions please do not hesitate to contact the residents’ group on ……………...
                        SECTION 11 APPENDICES

             INCIDENT/ACCIDENT RECORD FORM

This form is to be used to record any incidents where a young person is
hurt whether it is an accident (fell over, paper cut) or caused by the
actions of another young person/adult. It can also be used to record
bullying or abusive behaviour.

Name and date of the workshop/event:




Name of the young person

                                                      Age:

Description of what happened:




Signed by Worker:                             Date:




       Parents/Carers copy to be given to them on the day
Name of young person:

Description of what happened and any actions taken:




Signed by Worker:                                     Date:

Name in capitals:

								
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