GLOBESS - Induction & Health Surveillance

Title Page

Trade / Job title
Start date
Employee name
Profile photo
Date of Birth
Your Contact Number & E-mail address
Your Address
Nationality
Sex (Male/female/Other)
Date of Induction
Inducted by
Emergency contact - full name
Emergency contact - phone number
Relationship
Address
I confirm that i have submitted Evidence of rights to work in the UK to the Head office prior to works commencing.
Photo of evidence of right to work in the UK.

WORK AND BANK DETAILS

Unique Tax Reference Number (if applicable) (If you do not supply us with a UTR number, the applicable rate of tax shall be 30% (rather than 20%) in accordance with CIS rules).
Are you VAT registered?
VAT certificate submitted?
National Insurance number
Bank or Building Society name
Name of account holder
Branch
Account Number
Sort code
Building Society number (if applicable)
IMPORTANT - in the event the payments are requested to third party accounts, we will require written instruction and supporting explanation and identification of the nominated third party for security reasons.

Personal Details

Health Questionnaire Please tick YES or NO to each question. It is important that you answer each question truthfully.

HAND ARM VIBRATION SYNDROME QUESTIONNAIRE

Date of previous HAVS screening (if completed)
Have you been using hand held vibrating tools, machines, or hand fed processes in your job, (IF NO, OR MORE THAN 2 YEARS SINCE LAST EXPOSURE - NO NEED TO ANSWER FURTHER IN THIS SECTION.
Do you have any numbness or tingling of the fingers lasting more than 20 minutes after using vibrating equipment?
Do you have any numbness or tingling of the fingers at any other time?
Do you wake at night with pain, numbness, or tingling in your hands or wrists?
Have any of your fingers gone white with cold exposure? (Whiteness means a clear discolouration of the fingers with a sharp edge, usually followed by a red flush).
Have you noticed any change in your response to your tolerance of working outdoors in the cold?
Are you experience any other problems in your hands or arms?
Do you have difficulty picking up very small objects, eg screws or buttons or opening tight jars?
Has anything changed about your health since the last assessment?

MEDICAL QUESTIONNAIRE

Do you have any injuries or orthopedic problems (hernia, back, knees, shoulders, etc)?
Do you suffer from impaired vision (long / short sighted, or colour blind)?
Do you have any difficulty in hearing in normal conditions?
Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?
Do you suffer from any respiratory illness (COPD, asthma, etc) or have problems with nose, throat, or breathing when completing work activities?
Do you suffer from any stomach, bowel, bladder, hernia or kidney issues?
Do you suffer with any skin issues (dermatitis, or eczema)?
Do you suffer with any known allergies?
Do you suffer with Vertigo?
Do you suffer with Claustrophobia?
Do you suffer with Fainting or dizzy spells?
Do you suffer with Headaches / Migraines?
Do you suffer with Sinusitis?
Do you suffer with Tubercolosis?
Do you suffer with any blood borne disease, eg, HIV, Hepatitis?
Do you suffer with Anxiety, stress, or other nervous/mental disorder?
Do you suffer with Drug or Alcohol dependency?
Do you smoke or vape?
Do you suffer with Rheumatism, arthritis, tensons, ligament, joint issues?
Do you have any physical disability which could affect your work?
Are you currently taking any prescribed medicines that can make you dizzy or drowsy?
Have you ever been told that you suffer from a work related health problem?
Do you suffer from a frequent health problem that causes you to be off work for more than 2-3 times a year?
Have you ever had an illness or injury that has kept you off of work for more than 3 months?
Have you ever had to give up any previous job for medical reasons?
Have you ever received compensation for industrial injury or illness?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?
Do you have any difficulty in reading, writing, or may be dyslexic?
Do you suffer from epilepsy?
Do you suffer from Diabetes?
Do you have any other medical condition, injury, or anything else we should be aware of?

WORK ACTIVITIES THAT CAN AFFECT YOUR HEALTH

In previous employment, have you ever had significant exposure to;
Vibration
Dust
Noise
Manual Handling
Cancer causing agents
Radiation
Hazardous chemicals
Skin irritants
Lead
Asbestos
Mineral oils
Tar
If the answer to any of the above is yes, Please give details.
I certify that all the answers given are true to the best of my knowledge and belief.

POLICY CONFIRMATION

I have read and understood the H&S Policy that was issued during my HR induction.
I have read and understood the Environmental Policy that was issued during my HR induction.
I have read and understood the Environmental Policy that was issued during my HR induction.
I have read and understood the Drug & Alcohol Policy that was issued during my HR induction.
I have read and understood the Training Policy that was issued during my HR induction.
I have read and understood the Anti Bribery & Corruption Policy that was issued during my HR induction.
I have read and understood the Anti slavery & Human Traficking Policy that was issued during my HR induction.
I have read and understood the Personal Protective Equipment Policy that was issued during my HR induction.

TO BE COMPLETED BY THE OPERATIVE

I am able to communicate in English and understand health and safety signs or warning indicators (If the answer is No, then a further risk assessment and additional control measures will be required).
I am aware that i must wear Hard hats, high visibility jackets, safety footwear and gloves, along with any other necessary task specific PPE / RPE / FPE as identified by way of Risk Assessment.
I am aware that i am responsible for the maintenance, use, and safe keep of any PPE issued to me, and will be liable to reimburse Globe Group for any lost, damaged, or neglected personal protective equipment assigned to me.
I confirm that i must complete daily pre use PPE / FPE / Equipment checks (visual) prior to works commencing, In addition, a recorded check must also be completed on a weekly basis.
I agree that i must attend a site specific induction, and read and comply with the controls that are set out within the Method Statements, Risk / COSHH Assessments.
I am aware that I need to report Immediately to the Globe Group Management team ALL accidents, incidents, near miss incidents, and any hazards that i feel may cause harm or damage.
I have been advised of the location of the First Aid facilities, welfare facilities, and the fire assembly point.
I agree that i must have a CSCS / CISRS /CPCS / NPORS Card or equivalent to be able to work on a construction site / operate plant, and must not carry out any works, or operate any plant or vehicle that i have not been assessed as competent to do so.
I am aware that good housekeeping is mandatory and Globe Group operate a 'sweep as you go' policy. All rubbish and waste materials to be deposited in skips provided, and any materials must be stored in agreed locations and in an approved manner. <br>
I confirm that i will not put myself or others at risk of harm as a result of my acts.
I am aware that the company provided uniform must be worn. <br><br>
I am aware that Smoking or vaping is only permitted in designated areas.<br>
I agree that Mobile phones must not be used in work hours unless required for the nature of the business, or if Health and Safety is compromised.
I am over the age of 18 and have no medical conditions which will affect the safety of myself, or others whilst working.
Note 1: If under 18 – a separate risk assessment is needed
Note 2: Medical conditions - details must be submitted to HR.
Inductee Name and Signature

Competency / Qualifications

Please tick and provide photos (FRONT AND REAR) of relevant Training:
CSCS
CISRS
SSSTS/SMSTS
First Aid
CPCS / NPORS (Plant Operators)
Telescopic Handler
Asbestos Awareness
Abrasive Wheel
CCDO
Working At Height and Harness
Confined Spaces
Traffic Banksman
Fire Marshall
Slinger Signaller
Transporting Loads
Mobile Boom
Scissor Lift
Static Boom
Driving licence
If you hold any other qualification ensure that the office is aware and holds a copy for office records.