Date of Birth
Emergency Contact Information:
Do not carry out tasks involving the use of power tools or operate plant machinery unless you
have received formal training and are have a certificate to prove your training. Please indicate
below any Tools you are competent to use properly and safely and also any Training & Qualifications
held (e.g. Tickets Held, Training Undertaken, NVQs & Safety Cards)
Do you suffer from any health problems or have been seen by your GP in the last 12 months
concerning health problems, which may affect your ability to carry out your duties? (Incl. lifting,
manual handling, epilepsy, diabetes etc.)
Have you ever left, been retired from or denied a job on health grounds?
Have you ever been involved in an industrial accident and/ or made any insurance claims on a
previous employer for loss or compensation?
If you answered yes to any of the above, please give full details here
(e.g. illness, dates, medical attendance etc.)