TF008 – Health and Safety Questionnaire Health and Safety Questionnaire Health IssuesHealth – Illnesses Do you suffer from any illness which may affect you working with the following?Operating machinery?(Required) Yes No Heavy lifting?(Required) Yes No Working at heights?(Required) Yes No Driving vehicles or mechanical equipment?(Required) Yes No Working in confined spaces?(Required) Yes No Health – Conditions Please advise if you suffer with any of the following conditions and provide details below:Chest and respiratory conditions?(Required) Yes No Heart and cardiovascular conditions?(Required) Yes No Stomach and digestive conditions?(Required) Yes No Back, joint, limb or muscle strain?(Required) Yes No Ear problems or hearing impairment?(Required) Yes No Eye problems or vision impairment?(Required) Yes No Diabetes?(Required) Yes No Any other condition?(Required) Yes No Any other physical, mental or other condition that may affect your ability to perform your job role?If Yes, please provide details:(Required)If you have answered ‘Yes’ to having any other conditions, please provide as much detail as possible.Permission to disclose information?(Required) Yes No Do you provide permission to disclose information to client?Emergency ContactEmergency contact name(Required) First and Last Name Relationship to you:(Required) Emergency contact number(Required) Alternative Contact Number:(Required) Your DetailsYour Name(Required) Full name Your Email Address(Required) SignatureCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
