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Health and Safety/Next of Kin Form

Those who organise field trips are responsible for the health and safety of the attendees. For appropriate risk assessments to be made and the resultant control measures to be implemented, can you please fill out this health and safety questionnaire. The information collected will be treated with complete confidentiality.

Personal Information


Title: Given Name: Family Name:

Student Number: Course:


Next of Kin Information

Please provide details of your next of kin, this will be the person we will contact in the case of any emergencies

Name: Relationship to you:

Address:

Telephone Number

Day:

Night:

Medical Information

Please provide details of your GP (surgery/Practice name and address):

If you are not currently registered with a GP you must do so as soon as possible and provide the details to Angela Evans (Room 2.61).

UNTIL YOUR GP DETAILS ARE PROVIDED YOU WILL NOT BE ABLE TO ATTEND ANY NON-UK FIELD STUDY VISITS.


Do you currently or have you suffered with any of the following
(please tick the relevant box)

Heart and Circulatory Disorders

Heart Attack Heart Murmurs Angina Reynauds Disease

High or Low Blood Pressure Other


Blood Disorders

Anaemia Sicklecell Anaemia Haemophilia

Other


Psychiatric Conditions

Depression Nervous Debility Other


Medical Conditions

Asthma Epilepsy Hay Fever Crohns Disease Diabetes

Ulcerative Colitis Skin Conditions

Other


General

Are you in good health? Can you swim?

Is your vaccination status appropriate?

Do you have any allergies?

If yes, do you carry medication?

Are you Currently on Medication?


Disabilities

Please can you indicate if you suffer from any of the follwing disabilities whether they are registered or unregistered.

Visual Impairment Hearing Impairment Ambulatory Impairment

Hernia Arthritis or Joint Problem Back/Neck Problem

Arm/Leg/Foot Injury

Any Further Information:
   


Dietary Requirements

Please can you indicate if you have any special dietary requirements



Any Other Information

Is there any other information you can think of that may have an impact on or restrict the activities and objectives of a field trip as explained to you?