Health and Safety Self Assessment Questionnaire

All fields marked with a * are required entries

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	Health and Safety Self Assessment Questionnaire
	Health and Safety At Work Etc Act 1974 Section 20(2)(d)
	IMPORTANT THIS IS A LEGAL DOCUMENT This is a legally enforceable document which must be completed and returned to Environmental Health Department, Isle of Wight Council, within 21 days of the date of this document. PLEASE click here to read the notes carefully whilst completing the questionnaire. WARNING: Failure to return the questionnaire within the time indicated above, or providing false or misleading information, may lead to legal action being taken against you.

	Recipient Details
	Please enter contact name and business details below:

*	Contact name
*	Name of business

*	Building name/number
*	Street address
*	Town name
	County
*	Postcode
	Telephone number (include area code)
	Email address
	Fax

Fields marked '*' are required entries.

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