Health & Safety Form
Information on this form will be kept strictly private and confidential, should there be any further information required, the team will contact you directly.
Name
*
First Name
Last Name
Phone Number
*
Date of Birth
*
-
Day
-
Month
Year
Date
National Insurance Number
*
Site Qualifications
CSCS / NPORS / CPCS / Other
CSCS - I have a valid health and safety test dated within the last 2 years?
*
Yes
No
I hold a NVQ level qualification
*
Yes
No
I am over 21 years and hold a plant ticket
*
Yes
No
If yes, please attach a copy of your full drivers licence. Failure to attach this will result in you not being permitted to operate plant on site.
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Please upload copies of ALL your valid site cards and certificates (Front & Back)
*
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Next of Kin
Next of Kin Name:
*
Relationship to Next of Kin
*
Next of Kin Contact Number:
*
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General Health Surveillance
Private & Confidential
Are you on any long term medication? If so, give details.
*
Yes
No
Are you currently prescribed medicines that make you dizzy or drowsy? If so, give details.
*
Yes
No
Do you have any existing medical problems? If so, give details
*
Yes
No
Do you suffer from a frequent health problem that causes you to be off work more than 2-3 times a year?
*
Yes
No
Have you ever had serious diseases of joints, skin, nerves, heart or blood vessels? If so, give details
*
Yes
No
Has your health changed since the last assessment?
*
Yes
No
This is my first assessment
Have you ever had to give up any previous job for medical reasons? If so, give details
*
Yes
No
Please give further details here if required.
If answer is yes to any of the above questions, please give further information here.
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Medical Information
Do you have any of the following;
Asthma
*
Yes
No
Epilepsy
*
Yes
No
Dermatitis
*
Yes
No
Diabetes
*
Yes
No
Bronchitis
*
Yes
No
Conjuctivitis
*
Yes
No
Back Problems
*
Yes
No
Muscle Injuries/Strains
*
Yes
No
Hayfever
*
Yes
No
Migraine/Headaches
*
Yes
No
Heart Condition
*
Yes
No
Stress
*
Yes
No
Depression
*
Yes
No
Drug Dependency (If yes, give details)
*
Yes
No
Alcohol Dependency (If yes, give details)
*
Yes
No
Hernia
*
Yes
No
Blood Pressure
*
Yes
No
Tendon/Ligament/ Joint problems
*
Yes
No
Details
Please leave details of any medical information we need to be aware of
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Noise
Do you have difficulty hearing when there is a lot of background noise?
*
Yes
No
Do you have history of ear problems in the past? Or any history of deafness in the family?
*
Yes
No
Do you have history of exposure to gun fire or explosions? Or with previous employment
*
Yes
No
Do you have exposure to noise in leisure activities e.g. motorcycles, concerts etc
*
Yes
No
Have you worn ear protection in noisy environments?
*
Always
Sometimes
Rarely
Never
How do you consider your hearing to be?
*
Excellent
Good
Fair
Poor
I agree to wear noise protection when advised
*
I agree
Please provide further details if required
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Hand-Arm Vibration
Have you been using vibrating tools or machines in your job? (If no skip this section)
*
Yes
No
Do you have tingling of the fingers lasting more than 20 minutes after use?
Yes
No
Do you have numbness or tingling of fingers at any other time?
Yes
No
Do you wake at night with pain, tingling, or numbness in your hand or wrist?
Yes
No
Have any of your fingers gone white on cold exposure?
Yes
No
If yes to question above, do you have difficulty re-warming when leaving cold?
Yes
No
Do your fingers go white at any other times?
Yes
No
Have you noticed any change in your tolerance of working outdoors in the cold?
Yes
No
Are you experiencing any other problems with muscles or joints of the hand or arm?
Yes
No
Do you have difficulty picking up small objects e.g. screws or opening tight jars?
Yes
No
Have you ever had a neck, arm or hand injury or operation? If so, please give details
Yes
No
Please provide further details if required
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Skin
Have you experienced any type of rash or skin problems? If so, please give details
*
Yes
No
Do you have a rash or any skin problems at the moment? If so, give details
*
Yes
No
If you have reported this before, has it got worse?
*
Yes
No
Do you take any creams or medicine for any skin problems? If so, give details
*
Yes
No
Have you seen your doctor regarding any skin problems? If so, give details
*
Yes
No
Do you have any known skin disorder /disease? If so, give details
*
Yes
No
Do you have a family history of eczema?
*
Yes
No
Do you any current/previous allergies? If so,give details
*
Yes
No
I agree to wear gloves and protective equipment where required
*
I agree
Please provide further details if required
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Respiratory
Do you have a troublesome cough or bring up phlegm?
*
Yes
No
Do you suffer from shortness of breath?
*
Yes
No
Does your chest ever sound wheezy or whistling?
*
Yes
No
Do you ever experience chest tightness?
*
Yes
No
Do you a frequent blocked or runny nose?
*
Yes
No
Have you experienced your eyes being red, itchy or watery?
*
Yes
No
Do you have any allergies? If so, give details
*
Yes
No
Are you currently a smoker?
*
Yes
No
Have you ever been a smoker? If so, give details
*
Yes
No
Are you currently a vaper?
*
Yes
No
Have you ever been a vaper? If so, give details
*
Yes
No
Have you ever consulted a doctor about respiratory symptoms/problems?
*
Yes
No
Has it been necessary to provide you with respiratory protection at work?
*
Yes
No
I agree to wear respiratory protection where advised
*
I agree
If answered Yes - Please give more information on what was provided. Excludes masks for cutting etc.
How do you consider your respiratory health at present?
*
Excellent
Good
Fair
Poor
Please provide further details if required
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Other
Please provide further details of any other health issues. PLEASE PROVIDE YOUR HI- VIS SIZE READY FOR COLLECTION [S,M,L,XL)
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Declaration
I confirm that, to the best of my knowledge, the information provided in this questionnaire is true and accurate. I understand that providing false information or withholding relevant details may result in the termination of my services. I acknowledge the agency's open-door policy and understand that I can approach the Health and Safety Team or Management in confidence regarding any health concerns. I have disclosed all relevant health information as required.
Signature
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