Title Page
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Document No.
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Conducted on
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Conducted by
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Select Map location via Icon
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Employee Name
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Employee Qualification / Grade
- Ambulance Care Assistant
- Emergency Medical Technician 1 / Emergency Care Assistant
- Emergency Medical Technician 2 / Trainee Technician IHCD or AAP
- Emergency Medical Technician 3 / Qualified Technician IHCD or AAP
- Emergency Medical Technician 4 / Expanded Scope Technician IHCD or AAP
- NMC Nurse
- HCPC Paramedic
- HCPC Paramedic - Expanded Scope (Practitioner / ECP etc)
- GMC Doctor
- Other Qualified Health Care Professional
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Employee Base Station / Location
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EMPLOYEE PIN NUMBER
Section 2 Uniform Compliance
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Uniform Photo - Front - Behind (Ensure Epaulettes / ID Card Visible)
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Beanie Hat
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Epaulettes
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ID CARD
- Worn - Visible - Valid
- Worn Visible - Expired
- Worn - Visible - Incorrect Details / Damaged
- Worn - Not Visible
- Carried - Correct
- Carried - Incorrect / Damaged
- NOT Issued
- NOT Carried / Worn
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TRUST ID CARD
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FOB Watch
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CPR Face Shield
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Personal Hand Sanitizer
Section 3 Green Uniform
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Uniform Shirt
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Uniform Trouser
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Uniform Belt
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Uniform Jacket - Green
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Uniform Under Shirt (T-Shirt)
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SOCKS - BLACK, NAVY BLUE, DARK GREY<br>
Section 4 Personal Hygiene
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Head Hair
- Head Hair - Apparently / Visibly Clean, Tidy, Above Collar, Fringe above Eyes
- Head Hair - NOT Apparently / Visibly Clean, Untidy, Covers /Below Collar, Fringe over Eyes
- Head Hair - Unnatural / Non-Neutral Colour
- Head Hair - Radically Styled
- Hair not Visible - Covered by Approved Religious Garment
- Hair not Visible - Covered by Unapproved Religious Garment
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FACIAL HAIR
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Personal Hygiene
- Jewellery, Not Obtrusive / Likely to cause Injury (Plain Wedding band)
- No Visible Piercings other than Ear (Keeper - Ear Lobe ONLY)
- No Wrist Watch
- Visible / Other Piercings (Nose/ Lip / Tongue)
- Other Jewellery / Watch
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Apparently Clean - Free of Breath Odour
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Apparently Clean - Free of Body Odour
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Nails
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Hands
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Bare Below the Elbows
Section 5 Personal Protective Kit. PPE
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Safety Glasses
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Hi-Visibility Jacket
- Issue Hi-Visibilty Jacket - Clean
- Issue Hi-Visibilty Jacket - Correct Grade Badge (Front And Rear)
- Issue Hi-Visibilty Jacket - Correct Size
- Issue Hi-Visibility Jacket - Unclean
- Issue Hi-Visibility Jacket - Incorrect Grade Badge (front or rear)
- Issue Hi-Visibility Jacket - Incorrect Size
- Issue Hi-Visibility Jacket - Damaged
- Non-Issue Hi-Visibility Jacket
- NOT ISSUED A Hi-Visibility Jacket
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Hi-Visibility Vest
- Issue Hi-Visibility Vest - Clean
- Issue Hi-Visibility Vest - Correct Grade Badge (Front and Rear)
- Issue Hi-Visibility Vest - Correct Size
- Issue Hi-Visibility Vest - Unclean
- Issue Hi-Visibility Vest - Incorrect Grade Badge (Front or Rear)
- Issue Hi-Visibility Vest - Incorrect Size
- Issue Hi-Visibility Vest - Damaged
- Non-Issue Hi-Visibility Vest
- Not issued Hi-Visibility Vest
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Hi-Vis Trousers
- Hi - Visibility Trousers - Carried, Clean, Correct Size,
- Hi - Visibility Trousers - Not Carried
- Hi - Visibility Trousers - Carried, Incorrect Size
- Hi - Visibility Trousers - Carried - Dirty
- Hi - Visibility Trousers - Not Issued
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Safety Boots
- Issue Safety Boots - Worn
- Issue Safety Boots - Free of material defect
- Issue Safety Boots - Clean / Polished
- Issue Safety Boots - Unclean / Not Polished
- Issue Safety Boots - Damaged
- Issue Safety Boots - Laced Correctly w/Black Laces
- Issue Safety Boots - Worn Incorrectly / UnLaced / Incorrect Lace
- Non- Issue Boots
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Employee Signature
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Supervisor Signature
