RNM Health & Safety Questionnaire

• Please enter your personal details below.

• Name

• Mobile Number

• Email Address

• Proposed Role

• CSCS or Equivalent Card Held

  Yes

  No

  N/A

• Photo of FRONT & BACK of CSCS or equivalent card

  Media

• Any other relevant qualifications

  Yes

  No

  N/A

• Please list qualifications held

• Please fill in the details of your Emergency Contacts.

Details of 1st Emergency Contact

• Name

• Relationship

• Contact Number

• Address

• Post Code

Details of 2nd Emergency Contact

• Name

• Relationship

• Contact Number

• Address

• Post Code

• Occupational History

• HAS YOUR EMPLOYMENT EVER BEEN TERMINATED ON THE GROUNDS OF ILL HEALTH?

  YES

  NO

APPROXIMATLEY HOW MANY DAYS / WEEKS SICKNESS / ABSENCES HAVE YOU HAD IN THE PAST 12 MONTHS?

• MONTHS

• DAYS

MEDICAL HISTORY

• DO YOU SMOKE?

  YES

  NO

• DO YOU VAPE?

  YES

  NO

• ARE YOU CURRENTLY TAKING ANY PESCRIBED MEDICATION?

  YES

  NO

• ARE YOU CURRENTLY UNDER THE CARE OF A DOCTOR OR OTHER MEDICAL PROFESSIONAL?

  YES

  NO

ARE YOU CURRENTLY SUFFERING FROM OR HAVE SUFFERED FROM ANY OF THE ISSUES BELOW?

• HEART TROUBLE

  YES

  NO

• STOMACH / BOWEL TROUBLE

  YES

  NO

• JAUNDICE / HEPATITIS

  YES

  NO

• JOINT PROBLEMS

  YES

  NO

• HEADACHES / MIGRAINES

  YES

  NO

• DIABETES

  YES

  NO

• ASTHMA / ALLERGIES

  YES

  NO

• SEVERE STRESS REACTION

  YES

  NO

• KIDNEY / BLADDER DISORDER

  YES

  NO

• INJURIES AS A RESULT OF A SERIOUS ACCIDENT

  YES

  NO

• LUNG DISEASE

  YES

  NO

• HERNIA / RUPTURE

  YES

  NO

• BACK / NECK PROBLEMS

  YES

  NO

• FITS / BLACKOUTS / EPILEPSY

  YES

  NO

• DEPRESSION / ANXIETY

  YES

  NO

• HEARING / SIGHT PROBLEMS

  YES

  NO

• SKIN PROBLEMS

  YES

  NO

• SURGICAL OPERATIONS

  YES

  NO

• MOBILITY PROBLEMS

  YES

  NO

• HIGH BLOOD PRESSURE

  YES

  NO

• ACROPHOBIA (FEAR OF HEIGHTS)

  YES

  NO

• OTHER

  YES

  NO

• PLEASE PROVIDE DETAIL OTHER ISSUE

IF YOU HAVE ANSWERED “YES” TO ANY OF THE QUESTIONS ABOVE ON THE HEALTH & SAFETY QUESTIONNAIRE, PLEASE PROVIDE FURTHER DETAIL AND APPROXIMATE DATES WHERE RELEVANT. THE REASON FOR THIS INFORMATION IS TO IDENTIFY WHAT, IF ANY “REASONABLE ADJUSTMENTS” CAN BE MADE FOR YOUR EMPLOYMENT. THIS IS PARTICULARLY IMPORTANT WHERE YOU MAY HAVE A QUALIFYING DISABILITY UNDER THE DISABILITY DISCRIMINATION ACT 1995. PLEASE REQUEST ADDITIONAL SHEETS IF NECESSARY.

• IF APROPRIATE, PLEASE DETAIL BELOW

• SHOULD THERE BE ANY FURTHER INFORMATION CONCERNING YOUR HEALTH, SAFETY OR WELFARE THAT YOU WISH TO INFORM US ABOUT BUT HAS NOT BEEN INCLUDED IN THIS DOCUMENT, PLEASE ADD DETAILS BELOW.

• IN ACCORDANCE WITH THE REQUIREMENTS OF THE DATA PROTECTION ACT, THIS DOCUMENT ONCE COMPLETED, WILL BE MARKED “CONFIDENTIAL”, KEPT IN YOUR PERSONAL FILE UNDER CONTROLLED CONDITIONS AND ONLY THOSE PERSONS WITHIN THE COMPANY, WHO REASONABLY REQUIRE ACCESS TO IT, BY NATURE OF THEIR POSITION OF EMPLOYMENT, WILL BE ALLOWED ACCESS TO IT. INFORMATION WITHIN THIS DOCUMENT WILL NOT BE USED IN ANY IMPROPER WAY SO AS TO BE DETRIMENTAL TO YOUR CHARACTER.

• SHOULD YOU HAVE CONCERNS OVER POSSIBLE HEALTH & SAFETY USES WHICH MAY ADVERSELY AFFECT THE HEALTH, SAFETY AND WELFARE OF YOURSELF OR OTHERS DURING THE COURSE OF YOUR EMPLOYMENT, YOU ARE ENCOURAGED TO MAKE REPRESENTATION TO YOUR APPOINTED PERSON RESPONSIBLE FOR YOUR HEALTH AND SAFETY, AS DETAILED IN THE COMPANY HEALTH & SAFETY POLICY WITHOUT DETRIMENT TO YOUR FUTURE POSITIONS(S) WITHIN THE COMPANY.

SUBCONTRACTOR DECLARATION

• I HEREBY DECARE THAT THE INFORMATION GIVEN IS FULL AND TRUE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT, IF AT A LATER DATE, IT IS DISCLOSED THAT I HAVE KNOWINGLY WITHELD APPROPRIATE INFORMATION, DISCIPLINARY ACTION MAY BE TAKEN AGAINST ME, WHICH MAY ALSO INCLUDE DISSMISSAL.

• NAME & SIGNATURE

  Sign

• NAME AND SIGNATURE OF MANAGER

  Sign

• DATE

  Date