Health, Safety and Welfare at Work Report Form

1. Please use this form to report your concerns regarding health, safety or welfare to Environmental Health or to request advice from us.
  
  Please note: we can only deal with businesses or premises within the Preston City Council area.
  
  If the business or premises you wish to report is outside of our area, or you are not sure which Council to report the business or premises to, please visit GOV.UK - Find your local council and use their postcode checker to find the relevant local authority.
  
  If you are a duty holder (employer or self-employed etc.) who wants to make a report of an injury or dangerous occurrence under RIDDOR then you should do that on the Health and Safety Executive (HSE) website.
  
  All fields marked with * are required.
2. Please select the group that includes that description that best describes the type of premises or activity involved:
  
  Factories and manufacturing (including food manufacturers), farms, building sites, mines, Education (school, college or university), fairgrounds, gas, electricity and water works, hospitals and nursing homes, central or local government premises, offshore installations, residential accommodation (rented & communal area of flats etc), Veterinary Surgery, Car Wash, Crown or Government premises (including offices), Dentists, Delivery Personnel, Film or Radio broadcasting and recording, Motor vehicle repair & body shop (except those that only undertake MOT or tyre repair, Homeworker, Hospital, Parcel sorting & distribution, Police or Fire Authority, Prison
  
  Nuclear installation
  
  Food Business with poor food hygiene, food safety complaints or dirty food premises
  
  Problems with goods (product safety) and services you have bought
  
  Unstable or dangerous buildings
  
  Road Traffic incidents, including work vehicles on the highway
  
  Roadworthiness of vehicles
  
  Railway health and safety
  
  Care of patients and users of health and social care services (including care home residents).
  
  Aircraft, safety of flight crew and cabin crew on aircraft and health of passengers
  
  Marine safety including certification, pollution and health, safety and welfare of seafarers
  
  Office or Call centre (except government offices), retail (clothes and food shops, car showrooms, furniture and homeware shops/showroom, DIY/hardware shops) wholesale shop, holiday accommodation (Hotels, hostels, caravan parks etc), Premises selling food (restaurant, café, takeaway etc), leisure premises (leisure centre, gym, swimming pool, laser quest, cinema etc), nursery or playgroups, pubs and clubs, museums (privately owned), places of worship (Churches, mosques, Temples etc) warehouse or distribution centre, Residential Care Home * Sheltered Accomodation: Staff & Visitor Safety only, Salons (Hair, Nail, Tattoo, Beauty, Sunbeds, Chiropody etc), Commercial animal premises (Boarding Establishments, Pet Shops, Dog Groomers, Riding Stables, Livery but not Veterinary Surgeries), Undertaker, Sports Stadium, Mail order (letters) sorting & distribution, Mobile Vendor (Burger van, ice cream van etc), Taxi office
  
  Other
3. Please select the specific type of premises: (optional)
  
  Commercial animal premises (boarding establishments, pet shops, dog groomers, riding stables, livery - but not veterinary surgeries)
  
  Holiday accommodation (hotels, hostels, caravan parks etc)
  
  Leisure premises (leisure centre, gym, swimming pool, laser quest, cinema etc)
  
  Mail order (letters) sorting and distribution
  
  Museums (privately owned)
  
  Mobile vendor (burger van, ice cream van etc)
  
  Nursery or playgroups
  
  Office or call centre (except government offices)
  
  Places of worship (churches, mosques, Temples etc)
  
  Premises selling food (restaurant, café, takeaway etc)
  
  Pubs and clubs
  
  Residential care home or sheltered accomodation: staff and visitor safety only
  
  Retail (clothes and food shops, car showrooms, furniture and homeware shops/showroom, DIY/hardware shops)
  
  Salons (hair, nail, tattoo, beauty, sunbeds, chiropody etc)
  
  Sports stadium
  
  Taxi office
  
  Undertaker
  
  Warehouse or distribution centre
  
  Wholesale shop
4. CONDITIONALGUIDANCETEXT
  1. This activity is enforced by the Health and Safety Executive (HSE).
    Any reports should be made directly to them.
  2. This activity is enforced by the Office for Nuclear Regulation (ONR).
    Any reports should be made directly to them.
  3. This activity is dealt with separately, you can report this issue using the Food Safety Report form.
  4. These issues are dealt with by Lancashire Trading Standards.
    Any reports should be made directly to them.
  5. This issue is dealt with separately by our Building Control Team.
    You can visit our website to report a dangerous building.
  6. These incidents should be reported to Lancashire Police.
  7. This activity is enforced by the DVSA.
    You can make a report to them at GOV.UK - Contact the DVSA.
  8. Reports relating to railway safety should be made to the Office of Rail and Road.
  9. Patient and resident safety is the responsibility of the Care Quality Commission (CQC).
    Any reports should be made directly to them.
  10. These matters are dealt with by the Civil Aviation Authority.
    Any reports should be made directly to them.
  11. These matters are dealt with by the Maritime and Coastguard Agency.
    Any reports should be made directly to them.
5. Your details
  1. Name
  2. Address line 1
  3. Address line 2 (optional)
  4. Town/city
  5. Postcode
  6. Telephone number
  7. Email address
6. In relation to your query which of the following best describes you?
7. Why are you contacting Environmental Health today?
8. Please give details of the duty holder
  1. Business name
  2. Business address line 1
  3. Business address line 2 (optional)
  4. Business Town/city
  5. Business postcode
  6. Business telephone number (optional)
  7. Business email address (optional)
  8. Duty holder / Owner (optional)
  9. Named contact at the business (optional)
  10. Please give details of your concerns. Please tell us relevant dates and times of incident(s), location(s) within the premises, and the name(s) of person involved. Please be as accurate as possible.
  11. Please submit any photographs or documents that you would like the inspector to see (optional)
  12. FILEUPLOAD2 (optional)
  13. FILEUPLOAD3 (optional)
  14. Have you raised your concerns with the employer/duty holder?
    
    Yes
    
    No
  15. The inspector may ask you to raise your concerns with the duty holder before intervening in this matter.
  16. What was their response? (optional)
10. Preston City Council will use your information in a manner compatible with the General Data Protection Regulation (GDPR).
  
  Any disclosures or sharing of information will only take place where required or permitted by law. For further information please see our privacy notice .

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Health, Safety and Welfare at Work Report Form

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Health, Safety and Welfare at Work Report Form