Section 7
APPENDICES
FORMS, POSTERS & REFERENCES
Appendix 1
Policy Statement, Member signature forms & Reviews
Form One
Health & Safety Officer and Club Delegates
Form Two
Health and Safety Monthly Report Form
Form Three
Checklist for review of the Health and Safety manual
Form Four
Policy Review - for Annual General Meeting Endorsement
Form Five
Health & Safety Statement & signatory
Form Six
Annual Acknowledgement of Club Health and Safety Policy
Appendix 2
Hazard Controls and Risk Management
Form Seven
Hazard Identification Control Plan
Form Eight
New Hazards Notification
Appendix 3
Emergency Procedures and Forms
Form Nine
Evacuation Drill Report and Review
Form Ten
Accident Injuries and Near Miss Report
Form Eleven
Injury Report Form
Form Twelve
First Aid Minimum Requirements Checklist
Appendix 4
Display Wall Posters
Emergency Contact Information
Evacuation Flow Chart
Emergency Procedures Poster
Hazard Induction Form
Regulations for Visitors, Non Members and Contractors
References
Appendix 1 Form 1
HEALTH & SAFETY OFFICER AND CLUB DELEGATES
Club Name
Club Address
Club Phone Number
Name
Health and Safety Officer
Club President
Club Secretary
Club Treasurer
Committee Members
Phone Number
Appendix 1 Form 2
HEALTH AND SAFETY MONTHLY REPORT FORM
DATE
Completed Forms
Review
Health and Safety Policy Review
Yearly
Appendix 1 Form 4 and 5
Policy acknowledgement New Members
Monthly
Appendix 1 Form 1
Comments
Policy acknowledgement Visiting Groups
Monthly
Appendix 1 Form 3
Comments
Hazard Identification and Control Plan
Monthly
Appendix 2 Form 6
Comments
New Hazard identification
Monthly
Appendix 2 Form 7
Comments
Evacuation Drill and report
6 Monthly
Appendix 3 Form 8
Comments
Accident Incident Near Miss Reports
Monthly
Appendix 3 Form 9
Comments
Injury Report Form
Monthly
Appendix 3 Form 10
Comments
First Aid Minimum Requirements
Appendix 3 Form 11
Comments
Health & Safety Officer Signature
6 monthly
or as
required
Yes/No/ or N/A
Appendix 1 Form 3
CHECKLIST FOR REVIEW OF THE HEALTH & SAFETY MANUAL
Instructions: The General committee will schedule and complete an annual review of the Health and Safety
Policy. The review will give consideration to all parts of the policy using this checklist as a guide. On
completion each section of this form is to be dated and signed ready for endorsement at the AGM
Checklist
Health & Safety System
Policy Components
Club commitment to health and
safety, member information and
training
 Outline of Health and safety
programme (objectives)and
commitment
 Update legislation
 Induction process training and
development
Hazard identification
and management
 Hazard identification process and
risk analysis
 Forms for hazard identification,
analysis and management
 Manual handling guidelines
 Smoke-free workplace
Accident reporting and
management
 Procedures for investigating and
recording accidents. Forms for
recording accidents and
investigations

First aid
Emergency planning and readiness
 Disaster Management (Fire,
earthquake, flood
Roles and Responsibilities
Members, Committee, Health &
Safety Officer, Visitors and
Contractors
 Definitions
 Processes to ensure safety
 Responsibilities
Annual Review Date
Appendix 1 Form 4
POLICY REVIEW for Annual General Meeting Endorsement
Health and Safety Policy Review
Amendments: Section & Page Numbers
Approved (Signature)
Review Date
Appendix 1 Form 5
HEALTH AND SAFETY STATEMENT
PURPOSE
The purpose of this health and safety plan is to ensure every reasonable and practicable
effort is made to be sure that people attending or participating in club activities, or using
club facilities and amenities are not caused harm or injury by its activities or operations.
OUR HEALTH AND SAFETY VISION
Club Name will have a safe and healthy bowling environment for members, visitors and
others to enjoy
We believe that:



Health and Safety has priority over business and organisation objectives
Health and safety is the responsibility of every member and visitor to our Bowling
Club
All members have the responsibility to stop any practice or process they believe is
unsafe or cannot be continued in a safe manner, thus ensuring the safety of
themselves and others.
Policy Review and Audit Process





The Club Name will maintain and review Health and Safety Manual annually
The Health and Safety Officer will call a meeting with executive officers and
members who have designated areas of responsibility to confer and review the
health and safety processes
Any New Hazards will be dealt with as they arise and recorded on the Hazard
Control Plan
Existing Hazards will be re-examined to determine if they can be eliminated
All Health & Safety matters will be discussed and policy document scrutinized for
improvements
Club Name and Phone number
HEALTH AND SAFETY OFFICER
CLUB SECRETARY/ TREASURER
Policy Dated
2016/2017
DATE
NAME
SIGNATURE
Signature of one witness required
Appendix 1 Form 6
ANNUAL ACKNOWLEDGEMENT OF CLUB HEALTH AND SAFETY POLICY
By signing this form I acknowledge I have read and accept the NAME Bowling Club Health
and Safety Policy to which I agree to comply with at all times, including all the risks,
responsibilities and obligations, to which it refers.
I am aware that the form is valid for 1 Year (365 days)
Name ( Please Print)
Date
Signature
H & S Officer or Club Secretary
to sign
Appendix 2 Form 7
Name Bowling Club
HAZARD IDENTIFICATION CONTROL PLAN
E = Eliminate, I = Isolate, M = Minimize
Potential Harm
Hazard Controls
Completion
date
Hazard Identified
Risk
Low,
E, I, M
Med,
High,
Extreme
Monthly Check of Hazard Controls
Sept Oct
Nov
Dec/ Jan Feb
Mar
April
May
June
July
Aug
Appendix 2 Form: 8
NEW HAZARD NOTIFICATION FORM
Hazard Notification Form Name Bowling Club
Persons identifying new hazards must complete this form
Your Name
Date Hazard
Location
Notification to
Observed
Description of Hazard including
significance in your opinion
Any immediate action
taken to mitigate/
eliminate the hazard
Signature of person notifying
Health & Safety Report
Date form
completed
Date entered into
Hazard Control Plan
Signature of Health & Safety Officer
Appendix 3 Form 9
CLUB NAME EVACUATION DRILL REPORT & REVIEW
Name of Person Supervising Trial ...............................
Fire Service Advised ? .............................................................
Date Trial Conducted ............................
Time of Trial ......................................
1. Time taken to complete evacuation of building.
MINS
SECS
2. Could alarm be heard in all areas
YES
3. Were all smoke and fire control doors closed?
YES
NO
4. Were all wardens and those on site familiar with the evac. scheme?
Yes
NO
5. Did all wardens wear identification in accordance with the scheme?
YES
NO
6. Was a call made to the Fire Service using 111?
YES
NO
7. Was the correct Assembly Area used?
YES
NO
8. Are all evacuation procedure notices in place?
YES
NO
9. Are all exits clear and all doors able to be opened without a key?
YES
NO
10. Has all firefighting equipment been serviced in the last 12 months?
YES
NO
11. Next Trial evacuation scheduled ............. Date and time
Signed by ..................................................
NO
EVACUATION DRILL REPORT & REVIEW Continued
If you have checked any section, enter actions to rectify fault. Continue on separate page if
required:
Signed:
Site Health & Safety Officer
Minutes of Review Meeting for Evacuation Drill
Comments
Outcome
Signed:
Date:
Site Health & Safety Coordinator
Appendix 3 Form 10
Name Bowling Club
INCIDENTS, INJURIES FORMS AND NEAR MISS REPORT
NAME:
CONTACT NUMBER:
PARTICULARS OF ACCIDENT
Date of accident
Time
Location of Bowling Club
MTWTFSS
THE ACCIDENT
Describe what happened (Immediate Cause – determine and explain what caused the accident)
DID AN INJURY OCCUR
YES / NO (PLEASE CIRCLE) F YES PLEASE COMPLETE “INJURY REPORT FORM”
RETURN FORM TO THE PERSON IN CHARGE
Name Bowling Club
Appendix 3 Form 11
INJURY REPORT FORM
WHERE AND WHEN
Date
Time
Location
Event Participating in
Please also complete the “Accidents, Injuries and Near Miss Report” form as this gives details of
what happened when the injury occurred.
DETAILS
Name of person Injured:
Contact Number:
Name of Person Completing this form:
INJURY RECEIVED
Treatment provided:
Name of First Aider:
Did the injured require further treatment?
YES / NO (Please circle)
RETURN FORM TO THE PERSON IN CHARGE
Appendix 3 Form 12
FIRST AID KIT: MINIMUM REQUIREMENTS
Monthly Checklist
Item
6 x Disposable Rubber Gloves
Pack of Extra wide adhesive plaster strips
Fabric Dressing
2 x 10 cm wide Crepe Bandage
2 x sterile non-adherent pads Large
3 x sterile non-adherent pads Medium
3 x sterile non-adherent pads Small
Packet Leukostrip or similar wound closure varying in size
Leukostrip or similar standard strips ( for cuts)
2 Sterile eye pads
1 roll Paper tape
10 x sterile non -woven swabs
Roll of waterproof tape
10 sterile water wipes
2 x sodium chloride solutions
Paracetamol and Dispirin
Stainless steel scissors
Splinter tweezers
Packet of safety pins
Antihistamine cream Bites/Stings Optional
Eye wash
Optional/Recommended
Sunscreen Optional/Recommended
Foil Blanket Optional/Recommended
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr/May June/July August
DISPLAY WALL POSTERS
File an up to date copy of all Health and Safety wall posters here
Emergency Contact Information
Evacuation Flow Chart
Emergency Procedures Poster
Hazard Induction Form
Regulations for Visitors, Non Members and Contractors
EMERGENCY CONTACT INFORMATION
Emergency -- Fire/ Police/ Ambulance
111
Southland Hospital
218 -1949
Southland Police Station
211-0400
After Hours Doctor
218-8821
After Hours Dentist
218-6800
Civil Defence
0800 768-845
HSNO (Hazardous Substances)
0800 243-622
Medical Alert
0800 840-111
National Poisons Centre
0800 764-766
Alarm Goes off
Emergency Exits
are visible
Yes
EXIT
No
Walk
Emergency Signs
are visible
Yes
Follow
Directions
EXIT
Assembly Point
Emergency Procedures
FIRE:
If you discover a fire
Shout a warning
Operate the nearest Fire alarm
Ring 111 and give the location 85 Doon St Invercargill





When the fire alarm Rings
Leave the building immediately via the closest door
Go to the assembly area, walk, do not run.
Do not re-enter the building unless authorised to do so
EARTHQUAKE:
an discover
earthquake
FIRE:
If Ifyou
a firoccurs
Drop down low, under a door frame or table and cover
your head.
If it is safe to do so, leave the building immediately and go
to the assembly area.
Evacuation
Your exit route is the closest external door
Your assembly area is in the carpark
NAME Bowling Club
Please read our Hazard Induction Sheet:
Assembly Point
First-Aid Cabinet
Fire Appliances
Location
Location
Location
Fire
Earthquake
Dial 111
Evacuate via the closest exit
door
Don’t Panic
Drop Cover and Hold
Slips Trips and Spills
Weather
Take care with bowls,
lifters, bags, steps,
ditches and
uneven surfaces
Steps available. Please ask
Sunscreen
Slip, slop, slap
Drink water
Cover up.
Restricted Areas
No Smoking
All greenkeepers sheds
Behind the bar
Site specific …………………
Keep smoke drift from others
Watch out for
Fast Moving objects
Run Shots
Accident Incident Near Miss
Reports
If you are injured complete an
Accident Incident Report Form
located in the first aid cabinet
Alcohol
Drink wisely
and not on the green
Use the designated areas: …
Men at work
Red Disc in green
Means No Play
Greenkeeper, Gardners,
Contractors Volunteers
Chemicals, sprays or
unsuitable green conditions
Our Health and Safety Plan is available for you to read in the clubrooms.
Have a great day on the green and stay safety
INSTRUCTIONS: Cut and paste this form into the visitor’s book. Ensure all visitors, read it
and observe the induction poster prior to signing in.
REGULATIONS FOR VISITORS, NON MEMBERS AND CONTRACTORS
INSTRUCTIONS - PLEASE READ


Complete details on visitors book page
Do not sign until you have read the Health and Safety induction notices and
visitor disclaimer
Rules and regulations for all visitors








HEALTH & SAFETY in accordance with the Health and Safety At WORK ACT 2015
and amendments, and our Club Health and Safety Management Policy, visitors
and contractors must obey all reasonable instructions and agree to ensure that
their actions create no hazard to themselves or others
VISITOR INDUCTION includes reading the induction posters and evacuation plan
ALL VISITORS are to sign in. Your signature acknowledges acceptance and
understanding of all matters including the risks, responsibilities and obligations
of the Health & Safety policy
THE CLUB ACCEPTS NO RESPONSIBILITY for loss and/or damage of property, nor
injury attributable to any act created by other persons negligence
EVACUATION PROCEDURES. On hearing the alarm bell please leave the building
via the nearest exit door and proceed to the assembly point…
SMOKING is permitted in the designated smoking area …………………
In the event of an ACCIDENTS, INJURIES or NEAR MISS, report forms must be
completed.
For further information a copy of the Club Health & safety Policy is available
ENJOY A SAFE VISIT
REFERENCES
Injury Prevention, Rehabilitation, and Compensation Act 2001
Privacy Act 1993
Human Rights Act 1993
Health and Safety in Employment Act 1992 and Amendments
The Health and Safety in Employment Act 1992 and Amendments
The Health and Safety in Employment Regulations 1995
New Zealand Government: Work safe
Southern Institute of Technology
Surf Lifesaving New Zealand
The Sale and Supply of Alcohol Act 2012