Health and Safety Checklist

Ref: CF:025:01 RE: Safety Planning Checklist for the Physical Activity Programme, HSE
Issue date: May 2017 Review date: May 2019
Author(s): Members of the National Health and Safety Function, Health Promotion and
Improvement, Human Resources CERS and Healthy Ireland.

Note: This checklist is for use by Health Service Executive staff that are coordinating
and/or organising workplace physical activities. Such activities may be one-
offs or a series of events, which may run over a number of weeks (e.g. Pilates,
outdoor walking sessions). Such activities are part of the Healthy Ireland HSE
Staff Physical Activity Programme, 2016 as part of the HSEs’ Staff Health and
Wellbeing Strategic Priority (Healthy Ireland in the Health Services - National
Implementation Plan 2015-2017).

Who Is This Checklist For?

The HSE is committed to improving Staff Health and Wellbeing through workplace health
programmes. Workplace Physical Activities such as lunch-time jogging/walking, exercise classes, or
cycle events, etc. are positive initiatives to support staff wellbeing.

This Health and Safety Event Management pack is designed to support employees - “Workplace
Champions”1 - who organise/co-ordinate a workplace activity.

Am I Workplace Champion?

You are a “Workplace Champions” if you organise/co-ordinate a workplace physical activity.

As A Workplace Champion, What Are My Legal Obligations In Relation To Event Planning

And Preparation?

When organising an event you must take the necessary steps to assess and manage any health and
safety risks to participants. In order to comply with this requirement, you must complete the
attached safety planning checklist and ensure that any necessary remedial actions are identified and
implemented.

These obligations arise from the HSE’s duty of care under the Safety, Health & Welfare at Work Act
2005 to ensure, so far as is reasonably practicable, the safety of staff and others who may be
1
The terms “Workplace Champion” and event organiser are used interchangeably in this document

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 1
affected by its activities. In the context of this guidance/checklist such “others” would include
participants in workplace physical/wellbeing activities. The duty extends not only to the manner in
which activities are undertaken, but also the physical environment.

Are There Any Stakeholders I Should Consult With?

Yes, potential stakeholders include (non-exhaustively): Students, volunteers, service and contract
providers, emergency services, HSE Facilities Management (re: services, maintenance, rubbish/waste
removal and cleaning, parking and vehicle movements as appropriate), Security and the relevant
Local Authority (if event is to be held outside HSE premises).

What Is The Purpose Of This Checklist?

This “Activity Safety and Planning Checklist” provides a guide on the issues to be considered when
organising an event.

By using a systematic process of hazard identification, risk assessment and control, you can eliminate
or at least minimise the risk of untoward outcomes. It is intended to help you carefully plan your
event to ensure that nothing is left to chance.

When planning an activity or programme, it is important to remember that each activity is different;
from the type and number of people attending, to the nature of the activity.

Ultimately, effective planning means being prepared and ensuring that safety is a priority
throughout your event, from initial set-up to any dismantling when the event is over.

Notes:

 This checklist is intended to prompt you on matters for consideration and enable you to
document your activity safety plan
 For larger events some of the issues identified through the checklist may require a more detailed
risk assessment and consultation with local Management and/or local Estates/Facilities
Management
 You must present details of the event facilities and activities as part of the risk assessment. Site
Maps are useful for planning and should be available from your local Estates department
 While the safety checklist covers the most common and typical Health & Safety considerations
that arise during activity management, it is a non-exhaustive list
 You should identify and assess any hazards/risks for each activity and document the necessary
controls on the Risk Assessment pages: “Appendix II – Risk Management”

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 2
Do I Need To Carry Out A Health Screening Assessment With The Participants?

As a Workplace Champion you must ask participants to complete a short Physical Activity Readiness
Questionnaire (Appendix III). In completing the questionnaire participants confirm that they are
medically fit to partake in the activity and that they understand any risks associated with same.
Participants should be asked to disclose any medical conditions which may affect their ability to
participate before they commence.

Do I Need To Ensure That A Participant Attends Their Medical Practitioner If There Is An

Issue?

If the participant answered “yes” to any of the seven questions in the Physical Activity Readiness
Questionnaire (Appendix III) they must consult with their doctor before they participate in the
activity.

To Recap

1. Complete Parts A & B of the Activity Safety and Planning Checklist, Appendix I. This will help
you identify any potential risks
2. For each risk identified complete a formal risk assessment using the form in Appendix II - See
guidance documentation attached for further information on the risk assessment process
3. Ensure each participant completes the Physical Activity Readiness Questionnaire (PAR-Q) in
Appendix III
4. Confirm you have all the documentation by completing the: “HSE Safety Planning Checklist
for Physical Activity Events/Programmes Completion Form” in Appendix IV. This must be
signed by you and the relevant Senior Manager (General Manager or above)
5. Finally: Best of luck and thank you for being a Workplace Champion!

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 3
Appendix I: Activity Safety and Planning Checklist, Parts A & B:

Part A- Activity Programme Details:

Event Name:
Event Description:
Venue:
Venue Description
Location Address:
Proposed Event Date/s: From: To :
Estimated attendance
numbers:
Total Attendance (multi-
day events):

HSE Activity Programme Organiser Details

Group:

Address:

Main Contact Person:

Position:

Phone: Fax:

Mobile Email

Key Activity/ Programme Complete with all relevant contacts - internal and external
Contacts
Name Role Responsibility Contact details

Event Overall responsibility for activity/programme

Manager (if
different from above)
Health & Risk assessments, legal compliance, fire points,
Safety (where site inspections
applicable)

Other Key Contacts

Suppliers E.g.: equipment supplier
Organisation Contact name Service Contact details Notes

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 4
Authorities (Fire, Garda Siochana, First Aid etc. in the event of an emergency please dial
999/112 directly)

Organisation Contact name Service Contact details Notes

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 5
 Part B- Safety Checklist for Activities and Programmes:
Please complete all sections in full as appropriate to the proposed activity / programme.

HAZARDS/ISSUES OR TASKS Select which Additional Actions required

applies
Yes/No/NA
1. EVENT ACCESS AND EGRESS
Entry / Exit areas are clear and accessible for staff and
expected attendees
Entry / Exit areas are adequate for emergency exit and
emergency services
Thoroughfares are well defined and clearly marked
Access to and from car parking areas
2. TRAFFIC FLOW Select which Additional Actions required
applies
Yes/ No/NA
Clearly defined areas/paths for traffic, both vehicle and
pedestrian
Provision for safe passage of emergency / other vehicles
through pedestrian traffic
Controlled traffic flow and adequate signage for traffic
erected
Consider consulting An Garda Siochana if event is
organised on public road or access route
3. AMENITIES Select which Additional Actions required
applies
Yes/ No/NA
Adequate provision /location of toilets and hand washing
facilities – as per the general Applications Regulations,
2007 as amended
Availability of drinking water for staff and attendees
Adequate shade from sun / availability of sunscreen as If yes ensure the attendees are made
required for staff or attendees aware of the requirement to bring
necessary sun protection.
4. ACTIVITY/PROGRAMME SIGNAGE Select which Additional Actions required it maybe
applies necessary to Consult with your local
Yes/ No/NA Estates
Directional signage consistent and easy to relate to e.g.
pictograms to depict essential services and routes.
Adequate signage for entries, exits, toilets facilities, waste
or recycling bins etc.
Adequate signage for any hazardous /restricted areas
Clearly signed First Aid services and fire extinguisher
locations
5. ACTIVITY/PROGRAMME EMERGENCY Select which Additional Actions required
PROCEDURES applies
Yes/ No/NA
Emergency Plans documented and in place which should
include facilities, equipment, first aiders and fire safety
personnel.
Current fire safety site maps available e.g. “You are here”
drawings and Fire Action Notice

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 6
6. FIRE PREVENTION Select which Additional Actions required
applies
Yes/ No/NA

Fire fighting equipment available readily

accessible and tested
Access to personnel trained in fire safety as
appropriate
All staff and volunteers must be informed of the
fire evacuation procedures relevant to the
planned event prior to the event commencing
Note: All events must be notified to the HSE employee responsible for the site/location where the event is being
planned, this measure is required in the interest of fire and emergency safety. The responsible HSE employee must
also have the Event Programme Organiser contact details.
7. FIRST AID Select which Additional Actions required
applies
Yes/ No/NA
First Aid facilities available Go to www.hse.ie/safetyandwellbeing for more
information
First Aid box/stations suitably located, clearly signed
and accessible
Effective means of communication provided
between event personnel and First Aid facilities or
personnel
8. MAINTENANCE – insert contact no. Select which Additional Actions required
applies
Yes/ No/NA
Procedures for reporting issues/repairs to
maintenance for action
Records kept of any maintenance undertaken

9. ELECTRICAL POWER small domestic plug top appliances exempt

Power access required? Yes: No:
Details of power Generator 3 phase 240V
required
Estates Management must be consulted about electrical services available before activity and consider the following
Electrical Other: See Part 3 of the Safety, Select which Additional Actions required you may need to consult
Health and Welfare at Work (General applies with your local estates department to consider some
Yes/ No/NA of these issues.
Application) Regulations 2007 (S.I. No. 299
of 2007)
Portable Residual circuit devices (RCDs) are used
where required
Double adapters or piggy back plugs should not be
used
All portable (Specified) electrical equipment
including power leads, power boards are connected
to a Type 1 or 2 Safety Switch
Adequate protection of the public from electric
shock and any trip hazards
All electrical leads and electrical equipment are
placed in safe locations
All leads, plugs, etc. are protected from the weather
and hazards such as water or other liquids, etc.
Consider the provision of adequate emergency
lighting should normal systems fail

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 7
Generators (if used) are placed in a safe location
and are fenced or sectioned off from the public.
Exhaust gas is vented to an open air, not affecting
air intakes for HVAC systems.
10. UTILITIES / SITE SERVICES Select which Additional Actions required
applies
Yes/ No/NA
Any unsafe or restricted areas are communicated to
the Workplace Champion
Additional or alternate waste removal services have
been arranged with facilities or as appropriate
Adequate number of recycling and general waste
have been organised and located
Has venue cleaning been organised as appropriate
HSE Cleaning Co-Ordinator contacted: Name:

Phone: Email: Extra Bins Requested:

Cleaning requested:

11. NOISE Select which Additional Actions required

applies
Yes/ No/NA
Will the event include amplified music, speeches
etc.
Details of expected event noise:

Noise levels should not exceed the action levels set

out in the General Application Regulations, 2007
Noise control measures to be used to minimise
disruption to HSE business activity
Activity set up should not be permitted during night-
time hours in accordance with Environmental
Protection Agency Act 1992 i.e. Monday to Friday:
before 7 am and after 8 pm. Weekends and public
holidays: before 9 am and after 8 pm.

12. WORK AT HEIGHTS – Erection of banners, Select which Additional Actions required
flags or signs applies
Yes/ No/NA
Relevant and appropriate equipment must be
provided to complete the task in a safe manner.
Seek appropriate permission from Facilities/Estates
Management for erection of banners or other large
display items
Ensure ladders are well maintained and suitable for
work undertaken & weight – (industrial rated) add
in BS 2037:1994 Specification for Aluminum ladders
and BS EN 131-3:2007 – Ladders User Instructions
click here for user guide
No work should be undertaken from ladders unless
3 points of contact are maintained at all times e.g. 2
feet and 1 hand
Assistance of a second person is provided where

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 8
required e.g. holding ladder for stability, carrying
and erecting.
Right type of equipment is used for the height
access (i.e. ladder, cherry picker, etc.)
13. MANUAL HANDLING Select which Additional Actions required
applies
Yes/ No/NA
All staff and volunteers are trained to assess each
task and use safe technique when lifting or carrying
Loads are able to be delivered as close as possible
to area using vehicle or mechanical aids (e.g. trolley)
14. WEATHER CONDITIONS Select which Additional Actions required
applies
Yes/ No/NA
Current Met Eireann conditions information is
checked for adverse weather conditions
Weather conditions are planned for and monitored,
e.g. non-slip mats, shade, sunscreen and drinking
water available
Appropriate clothing based on weather conditions
15. PERSONAL PROTECTIVE EQUIPMENT (PPE) Select which Additional Actions required
applies
Yes/ No/NA
All tasks to be undertaken are checked to ensure
the appropriate PPE is available for staff and
volunteers. Separate risk assessments may be
required for high risk tasks
Personnel are trained in usage, maintenance and
storing of PPE
High visibility safety vests must be worn by staff as
deemed appropriate
16. ACCESSIBILITY Select which Additional Actions required
applies
Yes/ No/NA
Ramps are in place to provide access into buildings
Disabled Access Parking is available close to the
event
The activity itself is easily accessible (e.g. for patrons
in wheelchairs, using walking aids, etc.)
Entry / Exit area is easily accessible (e.g. for patrons
in wheelchairs, using walking aids, etc.)
Review accessibility arrangements in the event of an
emergency e.g. evacuation routes and assembly
points
17. OUTDOOR ACTIVITIES Select which Additional Actions required
applies
Yes/ No/NA
Route inspection completed
Hazards notified for correction e.g. potholes,
uneven surfaces, route isolation
Is event lighting adequate
An Garda Siochana should be consulted for outdoor
events and events making use of public facilities
Will the activity involve lone working
18. INDOOR ACTIVITIES/ PROGRAMMES Select which Additional Actions required
applies
Yes/ No/NA

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 9
Is the venue suitable for the intended activity, e.g.:
 it’s size
 is it adequate for the number of people
taking the class
 The locations accessibility for large
numbers
Is there potential conflict with competing uses
Identify any issues with the physical aspects of the
premises such as
 condition of the floor
 slip/trip hazards
 available and suitable equipment
 adequate ventilation
 heating
 lighting
 access to changing facilities
Have all floor surfaces been inspected for changes in
floor levels that may cause hazards
Have any slip, trips and falls hazards been identified
e.g. trailing cables (if yes then please highlight
additional control measures required)

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 10
Appendix II
RISK MANAGEMENT– IT’S A MUST
As part of any good planning process hazards should be identified and risks assessed and controlled
to minimise the potential for injury or harm. Events vary in size, nature and type, but all events
require assessment, control and monitoring of risks. When conducting a risk assessment, include the
people who are actually involved in undertaking the task.

HAZARD IDENTIFICATION
This is the process of recognising hazards associated with an activity and identifying the subsequent
risks to those people involved or likely to be exposed. Look for hazards (other than those specified in
this document) by considering them in groupings- Physical, Chemical, Biological and Psychosocial or
by Activity or Task.

RISK ASSESSMENT
The next step is to estimate the potential effects or harm of a hazard to determine its risk and an
appropriate rating. By allocating a risk rating, event organisers can prioritise risks in order of likely
severity to ensure that they deal with all risks systematically.

For information regarding the risk assessment process please click on the link provided here. The
HSE Health and Safety Risk Assessment Form is provided in Appendix 1 of this document. The Risk
Matrix in Appendix II will aid in calculating the impact scoring.

RISK CONTROL
In order to control the risk, work out the best method/s of treating the risk. Look at the following
methods, which are referred to as the ‘hierarchy of controls’, to see if you can eliminate or reduce
the risk.

• Elimination – by removing the hazard entirely through new design or implementing a new
process
• Substitution – by replacing hazardous materials or methods with less hazardous alternatives
• Engineering – by isolating, enclosing or containing the hazard or through design
improvements
• Administrative – by ensuring safe operating procedures are in place, and that effective
training, induction and monitoring is available to all in the workplace
• Personal protective equipment (PPE) – by making sure that appropriate safety equipment,
such as gloves, hats, sunscreen etc. are available.

In many cases consultation and discussion with people involved reveals new ideas or better ways of
handling hazards and reducing the risks of injury. Focus on what is both realistic and practical so that
risks are minimised to an acceptable level. It is vital to ensure that your risk assessment covers
hazards during the entire event – from set up to dismantling, not just during the event itself. Most
importantly, consult with those involved.

For further assistance and support please contact the health and safety helpdesk;
Please log your health & safety request at
http://www.hse.ie/safetyandwellbeing or go to
http://pndchssdweb02.healthirl.net/Health.WebAccess/ss
alternatively contact the National Health & Safety
Helpdesk on 1850 420 420 between 10:30-12:00 and
14:00 – 15.30.

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 11
 National Health and Safety Function, WHWU, Human Resources Division

Health & Safety Risk Assessment Form

Ref: CF:005:02 RE: General Risk Assessment Form

Issue date: May 2017 Review date: May 2019
Author(s): National Health & Safety Function

Legislation: Under Section 19 of the Safety, Health and Welfare at Work Act, 2005 and associated Regulations, it is the duty of the employer to
identify the hazards and assess the associated risks in the workplace. All risk assessments must be in writing and the necessary
control measures to eliminate or minimise the risks documented and implemented.

Note: It is responsibility of local management to implement any remedial actions identified.

Please note that to assist in carrying out the risk assessment an explanatory note on completing a General Risk Assessment is
included.

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 12
 Health & Safety General Risk Assessment Form

Division: Source of Risk:

HG/CHO/NAS/Function: Primary Risk Category:
Hospital Site/Service: Risk Type:
Dept/Service Site: Name of Risk Owner (BLOCKS):
Date of Assessment: Signature of Owner:
Unique ID No: Risk Coordinator:

PERSON DUE DATE

HAZARD & RISK DESCRIPTION EXISTING CONTROL
IMPACTS/VUNERABILITIES ADDITIONAL CONTROLS REQUIRED RESPONSIBLE FOR
MEASURES ACTION

INITIAL RISK RATING RISK STATUS

Likelihood Impact Risk Rating Open Monitor Closed

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 13
 Explanatory notes on completion of a General Health & Safety Risk Assessment Form
Division: Source of Risk:
HG/CHO/NAS/Function: Primary Risk Category:
Hospital Site/Service: Secondary Risk Category (s):
Dept/Service Site: Name of Risk Owner (BLOCKS):
Date of Assessment: Signature of Risk Owner:
Unique ID No:

PERSON DUE DATE

HAZARD & RISK DESCRIPTION
Using the Impact Context and Cause
(ICC) approach, describe the hazard
and associated risks.
For further information on this
approach please refer to Office of
Quality and Risk to access relevant
documentation.
IMPACTS/VUNERABILITIES EXISTING CONTROL MEASURES ADDITIONAL CONTROLS REQUIRED RESPONSIBLE
FOR ACTION
Refer to Impact Table as per HSE Risk Detail the control measures to Detail the measures necessary to Enter the date
Enter the name
Assessment Tool and enter the include all measures put in place to eliminate or further reduce the level of by which
of the
impacts and vulnerabilities that the eliminate or reduce the risks and risk. implementation
responsible
risk has on the employees, service include engineering controls, of additional
person for
users, and the organisation. policies, procedures, protocols, Consider the hierarchy of controls: controls to
implementation
guidelines (clinical and non-clinical), Elimination/ substitution/ engineering/ mitigate the risk
of each control
training, emergency arrangements, administrative/ PPE. are due.
measure.
preventative maintenance controls
etc. Consider the interim and long term
When examining existing control measures.
measures, consider the adequacy,
method of implementation and
level of effectiveness in eliminating
or minimising risk to the lowest
practicable level.

INITIAL RISK RATING RISK STATUS

Likelihood Impact Risk Rating Open Monitor Closed

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 14
Risk Assessment Tool:

Rate the risk in terms of determining the likelihood and the impact of the risk occurring.

Risk is measured in terms of likelihood and impact i.e. the likelihood of an event occurring combined
with its impact (consequence). The methodology for measuring risk in this way plots a single
ascribed value of likelihood against a single ascribed value of impact and therefore reduces risk to a
single, easily comparable value.

This process, except in the relatively rare case where statistical data is available, uses informed but
subjective judgment in assigning the values for likelihood and impact.

If different risks are to be compared across the HSE, it is necessary to minimise the variation in the
judgment applied to the values of likelihood and impact assigned to a risk. This requires the adoption
of a HSE-wide, standardised approach to the assignment of likelihood and impact.

Two elements are determined when assessing the level of risk posed by the risk that has been
identified;

(i) The likelihood that a specified event may occur or reoccur, and

(ii) The impact of harm to staff, services, environment or the organisation as a result of the
undesired event occurring.

Risk: The risk of a hazard is a measure of the likelihood or probability of an accident/incident

coupled with the severity of the injury, ill health, loss or damage. The risk of a hazard will be
assessed and ranked according to the categories below, on the Risk Assessment Template.

Likelihood Scoring

The likelihood table (table 2) is used to assess the likelihood of the risk occurring. Likelihood scoring
is based on the expertise, knowledge and actual experience of the group scoring the likelihood. In
assessing likelihood, it is important to consider the nature of the risk. Risks are assessed on the
probability of future occurrence; how likely is the risk to occur? How frequently has this occurred?

It should be noted that in assessing risk, the likelihood of a particular risk materialising depends upon
the effectiveness of existing controls. In assessing the likelihood, consideration should be given to
the number and robustness of existing controls in place, with evidence available to support this
assessment. Generally the higher the degree of controls in place, the lower the likelihood.

The assessment of likelihood of a risk occurring is assigned a number from 1-5, with 1 indicating that
there is a remote possibility of its occurring and 5 indicating that it is almost certain to occur.

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 15
Table 1: IMPACT SCORING

Score Impact

1 Negligible

2 Minor

3 Moderate

4 Major

5 Extreme

Table 2. Likelihood Table:

Table 3: Risk Matrix

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 16
To determine the impact of this harm should it occur, each risk area has been assigned descriptors
over 5 levels ranging from negligible to extreme harm. In scoring impact, the anticipated outcome of
the risk is grade from 1-5, with 5 indicating a more serious Impact, as defined in the table 3 below.

Each area of risk, in relation to the impact scoring, is outlined in table 4 on the next page.

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 17
17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 17
Appendix III
Physical Activity Readiness Questionnaire (PAR-Q)
Name:

Date: DOB: Age:

Home Phone: Work Phone:

Regular exercise is associated with many health benefits, yet any change of activity may increase the
risk of injury. Completion of this questionnaire is a first step when planning to increase the amount
of physical activity in your life.

Please read each question carefully and answer every question honestly: (Tick as appropriate)

Yes No
1 Do you have a heart condition and should only do physical activity
recommended by a physician?

2 When you do physical activity, do you feel pain in your chest?

3 When you were not doing physical activity, have you had chest pain in
the past month?

4 Do you ever lose consciousness or do you lose your balance because of

dizziness?

5 Do you have a joint or bone problem that may be made worse by a

change in your physical activity?

6 Is a physician currently prescribing medications for your blood pressure

or heart condition?

7 Are you pregnant?

8 Do you know of any other reason you should not exercise or increase
your physical activity?

If you answered yes to any of the above questions, talk with your doctor BEFORE you become
physically active. Tell your doctor of your intention to exercise and which questions you answered
‘yes’ to. If at any stage your health changes, resulting in a ‘yes’ answer to any of the above
questions, please seek guidance from a GP.

Participant’s Signature: Date:

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 18
 Appendix IV
HSE Safety Planning Checklist for Physical Activity Events/Programmes
Completion Form
Workplace Champion: Prestart checklist Have you?

Completed the details in Part A of this pack Yes No

Completed the safety checklist Part B

Completed any risk assessment as appropriate

Have attendees completed the Physical Activity Readiness

questionnaire

Signed off on this safety information pack

The Safety Planning Checklist has been completed and hazards identified for correction as appropriate
with the relevant parties informed of the recommendations if any.

___________________________________ ______________________
Workplace Champion Signature: General Manager Signature:

Date: /_____/_______ Date: /_____/________

17 05 02 CF:025:01 Healthy Ireland HSE Staff Physical Activity Programme, 2017 Page 19