Safety Statement

Safety Statement

Holy Family National School

Ballymote Road
Co. Sligo

Safety Statement

Holy Family National School

Health and Safety Policy Statement
The Board of Management of the Holy Family National School together with their Principal have set out a policy to comply with the Safety, Health and Welfare at Work Act 2005, and the Safety, Health and Welfare at Work (General Application) Regulations 1997.

We acknowledge that we have a responsibility to make our members/employees aware that we have an obligation to observe the regulations and statutory requirements as set down in the Safety, Health and Welfare at Work Act 2005.

This policy conveys to all members/employees, the attitude towards Safety, Health and Welfare.

To achieve this goal, requires total commitment of all members/employees.

To consult with all members/employees on matters of health and safety.

To provide and maintain, as far a reasonably practicable, a safe and healthy working environment for employees, pupils and others, and to meet our duties to members of the public with whom we come in contact.

To co-operate with, and seek the co-operation of members/employees, subcontractors to ensure work is carried out in a safe manner.

The Board of Management will review the contents of this Safety Statement as changes occur in this operation and periodically (Annually), evaluated to ensure this document is relevant. An inspection/safety audit will be carried out by either staff or a member of the Board of Management.

To ensure that the Health, Safety and Welfare of all employees are of the utmost of importance and to this end the Chairperson of the Board of Management/Principal has an active role in implementing its policies.
The employees must acknowledge that they too have their own responsibility to observe safe and good working procedures, utilising all equipment safely that is there for their benefit and co-operate fully with the safety personnel at the workplace.

The Code of Discipline in the school provides for a level of behaviour to minimise personal risk or stress to any employees.

The contents of this Safety Statement will be brought to the attention of all members/employees by providing them with copy of the document.


By adhering to the procedure as laid down in the Health, Safety and Welfare at Work Act, we hope that a safer place of work can be achieved. Thus reducing the possibility of accidents and realising safer and better working conditions for all concerned.

To ensure that the regulations are observed and guidelines are met and that all necessary records and reports are maintained and all notifications in accordance with the Health, Safety and Welfare at Work Act, are sent in.

The Chairperson of the Board of Management/Principal will be issued with specific instructions as to their responsibility to safety. To avoid death or injury, safety equipment that is supplied must at all times be utilised.

This Statement is distributed to all necessary personnel and shall be available for inspection at the Principals office.


____________________ Date:

Board of Management.


Members of the Board of Management:

Chairperson: Fr. Patrick Lynch



List of Members:



Safety Statement


This Safety Statement has been prepared for The Holy Family National School with the involvement of management. It has been compiled to comply with the Safety, Welfare at Work Act, 2005, the Safety, Health and Welfare at Work Regulation 1997 and other relevant legislation. This statement highlights the importance to reducing the possibility of accidents and ill health befalling our employees at their place of work.

It is not intended to state all hazards are under control at the time of inspection.

The final decisions must be made be the Board of Management and the Principal in the implementation of the Safety Statement.

Safety Statement



Chairperson of the Board of Management

The chairperson of the Board of Management, Fr. Patrick Lynch, working in conjunction with the Principal,Sr. Mary Richardson, has the overall responsibility for the planned implementation of effective health and safety standards to comply with current health and safety legislation, according to the agreed objectives, and for ensuring that health and safety standards are taken into account planning, carrying out, and in organising work generally.

The responsibilities are:

To ensure that, as far as is reasonably practicable:

That the place of work is designed, maintained and in a condition that is safe and without risk to health.

That the design, provision and maintenance of safe means of access to and from places of work.

That any equipment supplied is in good working order and regularly maintained.

That all members/employees are aware of the company policy with regard to safety and to know their own responsibilities.

The provisions of systems of work that are planned, organised, performed and maintained so as to be safe and without risk to health.

Adequate resources are made available to manage work safely and have the provisions on instruction to staff on proper lifting techniques of pupils and dealings with pupil challenging behaviour.

To provide information, instructions and/or training and supervision as is necessary to employees in order to ensure that they can carry out their work safely.
The provisions and maintenance of suitable personal protective equipment as necessary to ensure the safety and health at work of its employees.

The preparation and revision as necessary of adequate plans to be followed in emergencies: Evacuation procedures, Fire drills (at least on fire drill per term), Accident procedures etc.

That office documentation relating to accidents, diseases, equipment registers, and certificate of training are maintained.

To ensure that no teacher/employee is injured by physically violent pupil. Where appropriate support services will be brought in to help in the case of physical violence and/or sexually active children.

To ensure that access to employees is by consent. When the employee feels at risk from or threatened by a particular person on school property, this must be drawn to the Board of Management’s attention. The Board of Management will undertake to ensure that in such circumstances all appropriate measures will be taken to protect employees. Such measures will include meetings by appointment, with/without witnesses and, in extreme circumstances, an injunction/barring order and any necessary legal steps.

To review the safety procedures regularly and to ensure that they are adequate. To update periodically the safety policy in view of new regulations and charges in the management structure, etc. To seek the advice of a competent safety advisor if required.

To include in the annual report, an evaluation of the extent to which the safety statement was fulfilled during the period of the report.

The Chairperson of the Board of Management of The Holy Family National School recognises that its statutory obligations under legislation extends to students, any person legitimately conducting school business and the public.

A Safety Committee has been established to monitor the implementation of the Safety and Health Policies of The Holy Family National School and the requirement under the Safety, Health and Welfare at Work Act, 1989.

It is the responsibility of the Principal at The Holy Family National School to:

Implement the Safety, Health and Welfare Policy and to bring it to the attention of all employees and others in the workplace who may be affected by the Policy.

To ensure that visitors to the school comply with the safety, health and welfare procedures.

To organise the work areas so that work is carried out to the required standards and with the minimum of risk.

To know the board requirements of relevant Safety Legislation and Regulations and the specific safety requirements.

Plan and maintain a tidy workplace, arranging for the removal of refuse daily and ensure that employees including sub-contractors keep the work area tidy.

To identify and establish areas of responsibility with sub-contractors to avoid confusion

To check that all equipment, are maintained in good condition – if within their ability to promptly rectify defects.

To ensure that personal protective equipment is available, issued and worn.

To ensure that First Aid Boxes are maintained properly and that all employees know the location of the facilities.

To record all accidents in the manner set out in this document with a view to preventing reoccurrence.

Ensure that the workplace has, where necessary, suitable perimeter fencing to keep children and others away from danger.

To periodically inspect the workplace and rectify hazards identified.

To set good example at the workplace.
To provide safety awareness at the workplace and set personal examples to all employees and pupils.

To monitor the performance and effectiveness of the safety statement.

To ensure that statutory notices i.e. the safety policy statutory certificates are maintained or displayed in prominent locations.

To ensure a tidy workplace so far as practicable, in particular to ensure that adequate routes for access are provided.

To ensure that all personnel have appropriate fire fighting equipment and training at the workplace.

To arrange the provision for consultation with employees on matters of health and safety.

To arrange the provision for the selection from amongst its employees of a safety representative if required.

To arrange the provision and maintenance of welfare facilities of employees at work.

To ensure the safety and prevention of risk to health at work in connection with the use of any article or substance.

To obtain approval from the Board of Management before delegating any of these responsibilities.


It is the responsibility of all employees of The Holy Family National School to:

Familiarise themselves with, and conform to the Company Health and Safety Policy and to co-operate with their employer to ensure safe working conditions.

Ensure that they do not knowingly put them selves, or others at risk while carrying out their work.
Ensure that any safety equipment provided by the employer, where necessary are worn.

Make the Principal aware of any situations, which they feel is dangerous, and to report any defects in equipment to the Board of Management.

To report any accidents to the Principal.

Use the correct equipment for the job, ensuring that it is safe.

Ensure that they do not carry out tasks, which they feel they are not competent, or which involves unreasonably high risks.

To conform with instructions from the Principal.

Make suggestions or raise concerns with regards to safety, health and welfare to the Principal.

To observe all warning notices and instructions received.

To use any suitable appliance e.g. protective clothing, convenience, equipment or other means provided (whether for use alone or use by you in common with others) for securing their safety, health or welfare while at work.

Not to intentionally or recklessly interfere with, or misuse any appliance, protective clothing, convenience equipment or other means provided under legislation: (Safety. Health and Welfare at Work Act 1989, Safety, Health and Welfare at Work General Application) Regulations 1997 or otherwise for securing the Health and Safety of persons arising out of work activities.


In the event of sub-contractors being taken on, the following procedures will be carried;

Safety Statement

All sub-contractors will be expected to comply with their Company Policy for Health, Safety and Welfare and comply with this policy and any other requirements made known to them by the Board of Management/Principal.

A copy of their Safety Statement must be made available to Board of Management/Principal.


All sub-contractors will be required to provide evidence of adequate employer’s liability and public liability insurance prior to commencing work.

All sub-contractors must provide competent and suitable persons at the workplace and must get the approval of the Chairperson of the Board of Management/Principal to engage persons other that their direct employees.
Sub-contractors have a duty to report any defect in equipment place of work or system of work, without delay.
Sub-contractors must ensure that are aware of their obligations with regard to health and safety.
Sub-contractor are required to provide their own P.P.E.
Sub-contractors are required to provide certification of any relevant training pertaining to their specific job.


Consultation on safety matters will be in an informal manner between the Board of Management/Principal and Members/Employees. Any employee with concerns regarding safety matters should make these concerns known to the Chairperson of the Board of Management or The Principal.

To give a copy of the Safety Statement to all present and future staff.

All employees will be actively encouraged to voice any such concerns.

Consultation with the workforce is though staff meetings/committee meetings

The workforce will elect a Safety Representative should they wish to do so.

Consultation with Employees (Safety Representatives)

To give guidance on the role and function of Safety Representatives and the legislation relating to their activities.


Safety Representative:
Where persons are employed at any one time, employees at a place of work are entitled to select and appoint one of their number to act as a Safety Representative.

Function of Safety Representatives:

Safety Representatives may consult wit, and make representations to the employer on safety, health and welfare matters relating to the employees place of work. And the employer must consider these representations and act on them if necessary.

The Board of Management/Principal has responsibility for the management of safety. The appointment of Safety Representatives does not in any way remove this responsibility from management.

Safety Representatives have certain rights conferred upon them by the Legislation but are not legally liable to prosecution under the Safety, Health and Welfare at Work Act 1989, for failing to fulfil the function of a Safety Representative.

The Board of Management/Principal shall not place a safety representative at any disadvantage in relation to his/her employment arising from the discharge of his/her functions.

Investigations, Inspections and Consultations:

The Board of Management/Principal are specifically required under the legislation to make suitable arrangements for Safety Representatives to carry out investigation and work place inspections.

These should include:

Notification of specific incidents.
Access to premises and information.
Adequate fime and other assistance appropriate to the investigation.

Unsafe Conditions:

Safety Representatives may use oral or written representations to formally notify the employer of alleged unsafe or unhealthy conditions and working practices.
The Board of Management/Principal should respond by taking the appropriate remedial action within suitable time scales.
Should no remedial action by deemed necessary an explanation should be given to the Safety Representatives in writing.

The Board of Management/Principal are required to consult with Safety Representatives in order to achieve full co-operation and the establishment, promotion and maintenance of effective measures to safeguard the health and safety at work of all employees. This consultation should by on a wide scale but may include:

To carry out their safety function.
To acquire the knowledge necessary to discharge his/her function as a Safety Representative.

Time Off for Safety Representatives:

The Board of Management/Principal are required to ensure Safety Representatives are given reasonable time off work to fulfil their function.

Environmental, Health & Safety

There is a duty on all employees of The Holy Family National School to take care of their own safety, health and welfare while at work and ensure their safety and the safety of others are paramount and to co-operate with the employer to ensure a safe workplace.

The Board of Management/Principal of The Holy Family National School is committed to providing all of its employees with an environment free from harassment and stress.

Stress & Harassment at Work:
The Board of Management/Principal of The Holy Family National School is committed to providing all of its employees with an environment free from harassment and stress.


Ergonomics involves fitting the person to the job and fitting the job to the person. A preliminary ergonomic assessment undertaken of the plant highlights that areas exist where there are some risks or repetitive strain injuries and musculo-skeletal problems in the longer term. Associated problems will be solved through proper workstation design, work station layout and operator task alteration.
Ergonomics aspect of office safety, such as lighting, heating, ventilation, space, office furnishing, noise, office equipment, VDU technology, working station design are constantly monitored. All complaints and concerns are speedily acted upon.

Safety hazards in offices may result from:
Slips, trips and falls.
Collisions with furniture and equipment.
Injuries from hand tools such as pencils, staplers, paper cutters, office equipment and office furniture.
Floors made slippery by spilt liquid or improper maintenance.
Extension cords on the floor.
Door closers out of adjustment.
Splintered or broken furniture.
Paper, rags or other flammable materials left where they might ignite.

In The Holy Family School these risks are assessed as low and will be minimised further by maintaining good housekeeping and storage practices. Office furniture and fitting s will by kept in good repair. All office Personnel are responsible for maintaining their work area clean, organised and tidy and in having a daily and weekly Cleaning-Routine. Individual’s employee’s responsibility. All office Personnel are responsible for maintaining their work area, clean, organised and tidy and in having a daily and weekly Cleaning-Routine. Individuals must empty and tidy their Waste-Paper Baskets at the close of business daily. This is the individual employee’s responsibility. All obsolete and redundant furniture, equipment and files are removed to storage. All paper-files are returned to their proper location at the end of business daily. All P.C’s and other office equipment are switched off and made safe and secure before leaving the workplace.

EHS Training:

The purpose of this section is to ensure that any person who carries out work for The Holy Family National School has the necessary knowledge, experience and training to carry out there activities as to reduce the risk of accidents.

General responsibilities:

It is the responsibility of the Board of Management/Principal to ensure that all personnel appointed to work for The Holy Family National School have the knowledge, experience and training to carry out the duties assigned to them. If a person does not have this experience they should by under the supervision of a person who does.

Failure to comply with safety precautions will result in disciplinary action been taken.

Specialised training (typical examples):

First aid – The Statutory Requirement is to provide Trained First Aid cover for employees at work. The nature of the work, size, hazards, and location will all play a part in the number of trained personnel required. Any work activities will have first aid coverage. Personnel should know and where these people are. One First Aider is needed for every 50 employees, this availability should by recorded and available to review.

Manual Handling – Any transporting or supporting of a load, by one or more workers, including lifting, putting down, pulling, carrying or moving, which by reason of it’s characteristics or unfavourable ergonomics conditions, involves a risk, particularly of back injuries to workers. Where Manual Handling of loads cannot be avoided – training in safe manual handling techniques is obligatory.

Fire training – All personnel should know the action to be taken when fire alarms sound. (fire drills should take place at least once every term.) further training may be required in the safe operation and use of fire fighting equipment when dealing with small fires.

Equipment – Training shall be given to employees on the correct equipment required by them in the course of their work.

Records – Records should be kept of all personnel training, when they were trained and what the course covered. There records will be reviewed periodically.

Further Recommended Education Training – The curriculum is constantly under review. Any future training required will be complied with and implemented.

Future Legislation – The Legislation is always under review. Any future changes will be implemented.

Welfare Facilities

Office and Staff Room accommodation provided by The Holy Family National School should include but not be limited to:
Suitable table and chairs.
Water boiler/electric kettle where required.
Toilet/washing facilities and kept clean and checked regularly.

2. First Aid.
A first-aid kit(s) will be kept, maintained and re-stocked as necessary around the Workplace. Sub-contractors will have full use of these first-aid kit(s) for their employees. A first-aid kit will be kept in the office area. It is the policy of The Holy Family National School that all medications, drugs etc., be kept in a proper medication cabinet locked at all times, key to which is kept in a secure and safe place. No medication to be given by staff to pupils. The recommended content of First-Aid box is attached. As this Safety Statement relates to a school premises please note the following can also be held in first aid boxes. Wasp Eze, Burn Eze, Savlon Disinfectant and Savlon Cream.


It is the policy of The Holy Family National School that:
There is an adequate supply of fire extinguishers to deal with any type of fire.
All fire equipment is identified and regularly serviced.
Fire alarms are clearly marked.
Regular Fire drills take place (at least once per term).
There will be a named person in each area responsible for tire drills and evacuation procedures.
Training/Instruction is given in the use of Fire Extinguishers for specific material/equipment.
Exit signs are clearly marked to ensure employees/pupils/visitors are aware of exit doors.
All electrical equipment be unplugged or turned off outside office hours and when offices are vacated for lengthy periods.
Assembly areas are designated outside the building and are clearly marked.
Those leaving building/classroom should let someone know.

Safe Systems of Work

It is the policy of The holy Family National School to ensure that the tasks are within the competence and capacity of the employees. The systems of work will be designed with this purpose in mind. It is clear that some processes necessarily give rise to risks, which can only be controlled by adherence to proper procedures. The training provided to employees will identify the areas where care and skill must be exercised.

Is is the policy of Board of Management/Principal of The Holy National School when purchasing new equipment, altering existing equipment or changing a system of work, to ensure so far as is reasonably practicable that they are without significant hazard.

Systems of work include all normal work, maintenance work, and work by contractors, and include consideration for the safety and health of employees, pupils, visitors and public.

The board of Management, Principal and Employees of The Holy Family National School will ensure that they will comply with all the relevant legislation and guidelines while they carry out their work in relation to the following matters:

Personal Protective Equipment
Supply and Issue:
Supply the necessary P.P.E. to carry out their work safely.
Maintenance/Caretaker required the minimum of safety boots, high visibility jacket and ear defenders. (Where necessary goggles, face shield, gloves and mask).
Cleaners requires the minimum of gloves an protective apron.
Lolly-Pop Personnel requires the minimum of High visibility jacket (Where necessary weatherproof clothing).
All sub-contractors will be responsible for providing their own personnel with the same.
All employees and sub-contractors will wear the required safety equipment to carry out their work safely.
All employees and sup-contractors will wear sensible clothing suitable for their work.

A record of issue of P.P.E. should be kept and updated when necessary.
Manual Handling
To provide guidance on the safe and acceptable procedure for the preparation of manual handling activities. This procedure applies to all employees and sub-contractors at their place of work.

It you are uncertain about lifting a load – get help, do not put yourself at rick.
Use the following technique to lift safely:
Grip with all of the hands, not fingertips alone.
Get level with the load by bending the knees.
Keep your back straight and the load as close to your body as possible.
Lift using the leg muscles.
Try to arrange your system of work to minimise the need to left.
Plan ahead, make sure that your path is clear.
Get help when moving or placing ladders.
Roll gas cylinders along their base tilting them slightly.
Use mechanical lifting equipment where possible.

Should any child with special needs / disability be enrolled in the school, and requires lifting, then suitable arrangement will be made in terms of training in lifting and also support services, where practicable, in order to minimise strain on employees.


The school premises in its entirety is designated a Smoke Free Zone.

Infectious Diseases

It is school policy to notify all infectious diseases. The Holy Family National School wishes to ensure as far as reasonably practicable, the safety of staff, permanent, temporary or voluntary against all infectious diseases.

The Holy Family National School will endeavour to minimise the risk by:-
Adherence to sound principles of cleanliness, hygiene and disinfections have provided disposable gloves to be used for all First Aid applications, cleaning jobs etc. The staff have been provided with a separate toilet with hot and cold water, a disposal unit and soap.

Work Equipment

Work Equipment is all equipment provided for use at work, some of which will be governed to regulatory inspection requirements and will not be addressed in this standard. To identify with the equipment that requires regular inspection and identify the main hazards associated with the equipment.

It is the policy of The Holy Family National School that machinery, kitchen equipment and electrical appliances are used only by competent persons. Such appliances and equipment will be subject to regular maintenance checks.

Safe use of Hand Tools

To provide guidance on the safe and acceptable use of hand tools. This procedure applies to all employees and sub-contractors at their place of work.

Noise Control
To ensure that all activities that produce harmful noise is performed in a controlled manner and every opportunity to reduce the noise source is explored. When entering an eara where noise is above legal limits ear protection must be worn. This procedure applies to all employees and sup-contractors at their place of work. Where such work is taking place which constitutes any threat to Health and Safety the school will be closed or the work will not take place during school hours.

It is the policy of The Holy Family National School to minimise sound pollution – room to room, yard to room etc.


To provide guidance on the safe and acceptable procedure for the safe use of ladders, step ladders. This procedure applies to all contractors and sub-contractors on site.

Remember: The vast majority of ladder accidents occur because the ladder is not tied at the top.

Control of Hazardous Substances

To ensure that the health of employees and others is not affected by exposure to hazardous substances.

Material Safety Data Sheet (MSDS) – The Pro-forma that is supplied with a substance which contains the necessary information for the safe handling and use of chemical substances.

All chemicals, detergents, flammable, toxic and corrosive substances must be kept in the locked press/room provided. All the above substances must be at all times clearly and accurately labelled bearing instructions and precautions for their use.

Waste Control

To ensure that the disposal of waste arising from work activities is controlled. Wheelie Bin collection once a week, and recycling to centre.

House keeping “Clean as You Go”

To provide guidance on the safe and acceptable procedure for the Housekeeping standard.
This procedure applies to all employees and sup-contractors at their place of work.

No children are allowed to bring drinks in bottled glass to school to minimise the risks of breakages and cuts.

Safe use of Safety Signs and Barriers

Signs and barriers are erected to prevent unintentional or accidental access into a restricted area. To identify areas and the correct and safe use of Safety Signs, Fixed Barriers and Temporary Barrier Tape.

It is policy of The Holy Family National School that Floors will not be polished or made slippery. To eliminate the risk, the washing of floors is conducted after school hours. In the event of a spillage/leakage warning signs regarding wet/slippery floors will be used

Disciplinary Guideline for Safety Violations

Appropriate disciplinary rules & procedures are necessary for the consistent and fair treatment of individuals who, for whatever reason, – e.g. breach of safety regulations – may be subject to a disciplinary hearing by their employer.

Emergency Procedure Plan

Emergency Numbers 999 or 112

In the event to an emergency All employees/pupils are to obey instructions.

Evacuate site to designated point of assembly:

A roll call will by carried out to ensure everyone is present the relevant emergency services should by called out as soon as possible.

No one is to re-enter the building until same has been cleared by Principal/Person in charge.


Run to the assembly point.
Return to pick up any personal belongings.
Cause a distraction.
Cause an obstruction.
Prevent access for the Emergency Services
Engage in manning safety equipment unless you are an authorised trained and competent person.

Telephone numbers, to be contacted in an Emergency, are to be posted with Emergency Activator and deputies in a visible position, adjacent to telephone and will include the following:

Doctor: (Contact Hospital)

Fire Brigade:

Chairperson Board of Management

Principal Phone No: (School)
Accident and Incident Investigation

To ensure the timely and efficient response to accidents and incidents and that they are fully investigated and any lessons learnt are properly communicated.


Accident – Unplanned unwanted event.
First Aid Injury – An minor injury that requires treatment by a first aid trained person.
Medical Treatment Injury – An injury that requires treatment by a medically trained person (nurse or doctor).
One Day Lost Time Injury – An injury that results in the person being absent for the one day (but does not include the day of the accident).
Three Day Lost Time Injury – An injury that results in the person being absent from work for more than 3 days following the accident (but does not include the day of the accident).
Incident – An accident that results in damage to equipment or property but does not result in injury to personnel.
Near Miss – An accident that results in an event (such as a falling object) but ne damage to equipment, property or injury occurs.
Dangerous Occurrence – An incident that is so serious that one or more personnel could have been seriously injured and is prescribed by legislation.
HAS – Health and Safety Authority (Ireland).



Must report all injuries or incidents to their principal, no matter how small or insignificant they feel they may be.


Commence an investigation as soon practicable after the event

Complete the Incident Report Form for Medical Treatment or potential Lost Time Injuries.
In more serious accidents the area may have to by made safe and controls put in place to prevent access by others and to ensure the scene is not altered before the higher level investigation.
Ensure the supervisors respond to the accident in a timely manner and any actions from the investigation are carried out to prevent recurrence.

Doctor/Occupational Health Nurse:

Will complete the Medical, First Aid Preliminary report form when an injury is reported to him/her.
Board of Management:
They have systems in place to support the investigation of accidents and incidents and communicate any follow up actions.
Root cause of accidents is to be used in the investigation of Medical Treatment and Lost Time Injuries and Dangerous Occurrences.
The Medical Treatment, Lost Time Injuries and Dangerous Occurrences that occur within their area of responsibility are fully investigated.
They must chair the inquiry meeting within 24 hours of the event.

Safety Officer:
A system is in place to keep the Board of Management fully informed of the investigation status of the accident or incident.
Reports to the HAS are carried out as necessary.
A meeting of the Board if Management is held to discuss any injuries or incidents reported.
Findings and learning are communicated to the Principal.
Investigation reports are transmitted to the Board of Management within 5 working days of the accident or incident.
A system for monitoring the closure of actions is maintained and reviewed.
Copies of investigations are sent to the Board of Management for circulation to employees.



Doctor/OH Nurse to complete sections 1-6 and Part 1 of Section 7 for each injury
Doctor/OH Nurse to complete Parts 2 & 3 of section 7 for any injury requiring off-site treatment
Doctor/OH Nurse to take form to daily review with EHS Safety Team
Safety Officer to complete section 8 and communicate requirement for further investigation to the Board of Management/Principal (verbally and by copy of this form)
Safety Management Team will, weekly, check
Status of injured person until section 7 closed out.
Update section 8 when investigation report is received.
Complete section 8 when investigation actions are complete.
Section .1
Date of Incident: Time of Incident: Place of Incident:

Name of Injured person: Company: Position:

Supervisors name:

Date of Birth: Date & time Incident reported:
Section .2

ACTIVITY employee was performing at time to Incident. Describe in detail the action, occurrence of avent that result in the Incident (encounters with machine, exposure to chemicals, lifting, tripping, etc).

Section .3

LIST PPE (Personal Protective Equipment), safety devices or other equipment in use at time of incident.

Section .4
WITNESSES – List any witnesses
Company: Name (Print) Position:

Section .5
DOCUMENATION is the injured person aware if any of the following are in place.

Safety Statement ? Yes ? No

Risk Assessment ? Yes ? No

Were they being followed? ? Yes ? No
Section .6 (This section may be required to be completed later)
STATUS of Treatment

Treatment type
First Aid ? Hospital A & E ? Medical treatment ? OH Physician Review ?

2. Review of individual required YES NO Date & Time of review:

Section .7 (This section may be required to be completed later)
STATUS of Injured person

Part 1. Injury type
First Aid ? Medical treatment ? Lost Time Accident (OSHA – 1 day) ? Lost Time ?
Accident (HAS – 3 day) ?

Part 2. For Injuries requiring off-site medical treatment

Individual has returned to work on light duties (if applicable).

Injured Person Name (Print) Sign: Date & Time:
Supervisor Name (Print) Sign: Date & Time:

Individual has returned to work on normal duties.

Injured Person Name (Print) Sign: Date & Time:

Supervisor Name (Print) Sign: Date & Time:

Section .8

The Board of Management/Principal of The Holy Family National School

Is further investigation required? ? Yes ? No

Has investigation report been completed? ? Yes ? N/A

Have actions been completed? ? Yes ? N/A

On behalf of The Holy Family National School.

Name (Print) Sign: Date & Time:


Report / Safety Statement Review


The Board of Management at The Holy Family National School intends, annually, to review this Safety Statement in order to ensure its suitability, adequacy and effectiveness.