Combined written safety statement and risk assessment — mandatory in writing for every employer regardless of size, under sections 19 and 20 of the Safety, Health and Welfare at Work Act 2005.
⚠️ This is a blank template, not legal advice: check the wording with a lawyer and adapt it to your jurisdiction and your case.
This template has no optional clauses: the text is the same for everyone. Field placeholders are shown as labels — on the site the template is read-only, values are entered inside the system.
SAFETY STATEMENT AND RISK ASSESSMENT (Sections 19 and 20, Safety, Health and Welfare at Work Act 2005)
Business: Business name Business address
This Safety Statement is a written document, required of every employer regardless of size, setting out how safety, health and welfare will be managed at this workplace. It is based on the identification of hazards and assessment of risks required by section 19, as required by section 20 of the Act.
1. RESPONSIBLE PERSONS 1.1. Persons responsible for safety and their roles
2. HAZARD IDENTIFICATION 2.1. Hazards identified
3. RISK ASSESSMENT 3.1. Risk assessment
4. PROTECTIVE MEASURES AND RESOURCES 4.1. Protective measures & resources
5. EMERGENCY PROCEDURES 5.1. Emergency procedures
6. EMPLOYEE DUTIES 6.1. Employee duties 6.2. Every employee must comply with this Safety Statement and cooperate with the employer on safety matters, as required by section 13 of the Act.
7. CONSULTATION 7.1. Consultation & safety representative arrangements
8. REVIEW 8.1. This Safety Statement must be brought to the attention of all employees, and reviewed whenever there is a significant change in the work or workplace, or on the direction of a Health and Safety Authority ("HSA") inspector (normally within 30 days). 8.2. ⚠️ Employers with 3 or fewer employees may follow a relevant HSA Code of Practice instead of a separate written Safety Statement, where one exists for the sector — a written risk assessment is still mandatory in every case. HSA's free BeSMART.ie tool provides sector templates for around 400 business types.
Prepared by Prepared by on Date.
SIGNATURE ______________ / Prepared by /
— — — ⚠️ This is a boilerplate template, not legal advice. Employment, health & safety, food safety, and consumer-protection law in Ireland changes frequently (e.g. the Employment (Miscellaneous Provisions) Act 2018, the EU (Transparent and Predictable Working Conditions) Regulations 2022, and Workplace Relations Commission Codes of Practice) — have this document reviewed and adapted by a solicitor (and, for employment matters, checked against the current WRC Code of Practice at workplacerelations.ie) before use.
Fields that belong to a switched-off clause are dimmed — they are not asked for.
For each hazard: who is at risk, existing controls, risk rating, further action, responsible person, review date
2 of 11 fields are taken from the company, employee or counterparty record, the questionnaire can be dictated to the AI, and the finished document comes with a number, a PDF and an acknowledgement record.