ࡱ> uwt'` !TbjbjLULU 6V.?.? 2222222F8lVF|R~ddddCvCD=D$QQQQQQQ$jShUvQE2HCC@CHHQ22dd&6RUIUIUIHR2d2dQUIHQUIUII22gLd @91eHjWLO LR0|R_LHVH4HVgLHV2gLXaD+EUIEt/FaDaDaDQQIRaDaDaD|RHHHHFF$j  FFjFFF222222 UCL Human Resources Division OCCUPATIONAL HEALTH SERVICE SAFETY CRITICAL WORK HEALTH SCREENING FORM. Your manager has advised us that your role at 911ill involve safety critical work. This may be, for example, working at heights or in a category 3 laboratory. The Occupational Health Service therefore requires information about any significant physical or sensory impairment that may increase the risk of accident or illness at work so that we can assess and advise on any precautions or support measures necessary to mitigate the risk, if appropriate. After discussion with you, we will then advise your manager in regards to these. We will not divulge any underlying health issues without your full consent. YOUR DETAILS:Date of birth FORMTEXT      Surname FORMTEXT      Forenames FORMTEXT       Title  FORMTEXT      Contact details- home FORMTEXT      - mobile FORMTEXT      - work FORMTEXT      - email FORMTEXT       1.Have you ever had blackouts, seizures or fits?Yes  FORMCHECKBOX  No  FORMCHECKBOX 2.Have you ever been diagnosed with a heart condition or an irregular heartbeat?Yes  FORMCHECKBOX  No  FORMCHECKBOX 3.Have you ever had repeated episodes of giddiness or vertigo?Yes  FORMCHECKBOX  No  FORMCHECKBOX 4.Do you have any condition that affects your balance or coordination?Yes  FORMCHECKBOX  No  FORMCHECKBOX 5.Do you take any medication (prescription / over-the-counter) that can cause drowsiness, e.g. sedatives, anti-depressants, anti-histamines? Yes  FORMCHECKBOX  No  FORMCHECKBOX 6.Do you have a condition, such as diabetes treated with insulin or drugs that may cause a sudden loss of consciousness?Yes  FORMCHECKBOX  No  FORMCHECKBOX 7.Do you have any visual problems that are not corrected with glasses?Yes  FORMCHECKBOX  No  FORMCHECKBOX 8.Does your alcohol intake impact on your performance in the workplace?Yes  FORMCHECKBOX  No  FORMCHECKBOX 9.Do you have a physical or mental impairment which may impact on your safety at work?Yes  FORMCHECKBOX  No  FORMCHECKBOX  I declare that all the questionnaire responses are true to the best of my knowledge. I understand and accept that I may be required to attend for an Occupational Health assessment or health surveillance. I understand and accept that further medical information may be requested from my doctor if considered necessary and subject to the occupational health adviser obtaining my consent under the Access to Medical Reports Act 1988 Signature: Date: If completing this form electronically, please type your name above, save this form locally and then email it back to us form your personal email account. If we require further information from your GP or Specialist we will contact you to discuss obtaining your written consent. Please email the form to  HYPERLINK "mailto:ohsadmin@ucl.ac.uk" ohsadmin@ucl.ac.uk, or post to Occupational Health, UCL, Gower St<=?klf ǿyyeUC8h-h,OJQJ#h-h,6CJOJQJ^JaJh-h,5CJOJQJaJ&h-h,56CJOJQJ^JaJ h-h|SCJOJQJ^JaJ h-h,CJOJQJ^JaJ#hh,5CJOJQJ^JaJ#h-h,5CJOJQJ^JaJh,CJaJ h,5CJOJQJ\^JaJh-h,CJOJQJaJ0jh-h,CJOJQJUaJmHnHu <=>?kl  $H&`#$/If^`gd-$Fdhx]F^a$gd|S$F]F^a$gd,F]Fgd,gd,gd, h^`hgd, T T     * , . 8 : < N P R f h j t v | ꛊx`xHx/jh-h,CJOJQJU^JaJ/j8h-h,CJOJQJU^JaJ#h-h,6CJOJQJ^JaJ hh,CJOJQJ^JaJh-h,OJQJ4jh-h,CJOJQJU^JaJmHnHu/jh-h,CJOJQJU^JaJ h-h,CJOJQJ^JaJ)jh-h,CJOJQJU^JaJ   < P | dNNNNNNxx$H&`#$/Ifgd-kdv$$IflFP(T$ t 6`H04)    44 layt-     2 4 6 @ B D F V X l ҷҦҦkҷҦҦSҷҦҦ/jSh-h,CJOJQJU^JaJ/jh-h,CJOJQJU^JaJ#h-h,6CJOJQJ^JaJ hh,CJOJQJ^JaJ h-h,CJOJQJ^JaJ4jh-h,CJOJQJU^JaJmHnHu)jh-h,CJOJQJU^JaJ/j$h-h,CJOJQJU^JaJ kd$$Iflֈ\t"( $ T t 6`H04)44 lap<yt-  D xx$H&`#$/Ifgd-D F H V ~ >(((xx$H&`#$/Ifgd-kd$$Iflr &(BR r0 t 6`H04)44 layt-l n p z | ~ ҷҦҦ|ҷҦkgXLXLXh|SCJOJQJaJh|Sh|SCJOJQJaJh, hh,CJOJQJ^JaJ/j-h-h,CJOJQJU^JaJ#h-h,6CJOJQJ^JaJ h-h,CJOJQJ^JaJ4jh-h,CJOJQJU^JaJmHnHu)jh-h,CJOJQJU^JaJ/jh-h,CJOJQJU^JaJ~ (kd$$Iflr &(BR r0 t 6`H04)44 layt-xx$H&`#$/Ifgd- >?B[kd}$$IflF, `'q  t0(6    44 layt dh$Ifgdgd,"#$'),-;<=>?ABuqeVeV>/h|Sh56B*CJOJQJ^JaJphh|ShCJOJQJaJhCJOJQJaJh|S>jh|Sh|S56B*CJOJQJU^JaJph)h|S56B*CJOJQJ^JaJph>jh|Sh|S56B*CJOJQJU^JaJph8jh|Sh|S56B*CJOJQJU^JaJph/h|Sh|S56B*CJOJQJ^JaJph˫˖vrfWfW7>j h|Sh56B*CJOJQJU^JaJphh|ShCJOJQJaJhCJOJQJaJh>j h|Sh56B*CJOJQJU^JaJph)h56B*CJOJQJ^JaJph>j4 h|Sh56B*CJOJQJU^JaJph/h|Sh56B*CJOJQJ^JaJph8jh|Sh56B*CJOJQJU^JaJph0l``` dh$Ifgdkd $$IflF, `'q  t0(6    44 layt-./0134xy}~˶˖˒wwW˶>jz h|Sh56B*CJOJQJU^JaJphh|ShCJOJQJaJhCJOJQJaJh>jM h|Sh56B*CJOJQJU^JaJph)h56B*CJOJQJ^JaJph/h|Sh56B*CJOJQJ^JaJph8jh|Sh56B*CJOJQJU^JaJph014yl``` dh$Ifgdkd $$IflF, `'q  t0(6    44 layt78<=KLMPRUVdefgëëlëWë7ë>jh|Sh56B*CJOJQJU^JaJph)h56B*CJOJQJ^JaJph>jh|Sh56B*CJOJQJU^JaJphh|ShCJOJQJaJhCJOJQJaJh/h|Sh56B*CJOJQJ^JaJph8jh|Sh56B*CJOJQJU^JaJph>j h|Sh56B*CJOJQJU^JaJph8gl``` dh$Ifgdkdf $$IflF, `'q  t0(6    44 laytghkl``` dh$Ifgdkd $$Ifl1F, `'q  t0(6    44 laytghjkYZ^_mɬɌwɬWɬ>j6h|Sh56B*CJOJQJU^JaJph)h56B*CJOJQJ^JaJph>jh|Sh56B*CJOJQJU^JaJph8jh|Sh56B*CJOJQJU^JaJph/h|Sh56B*CJOJQJ^JaJphh|ShCJOJQJaJhCJOJQJaJhZl``` dh$Ifgdkd$$Ifl1F, `'q  t0(6    44 laytmnortwxëëvërfWfKfKWëhzCJOJQJaJh|ShCJOJQJaJhCJOJQJaJh>jh|Sh56B*CJOJQJU^JaJph)h56B*CJOJQJ^JaJph/h|Sh56B*CJOJQJ^JaJph8jh|Sh56B*CJOJQJU^JaJph>jch|Sh56B*CJOJQJU^JaJphl``` dh$IfgdkdO$$IflF, `'q  t0(6    44 laytZ[_`nopsëëvërfWfWë7ë>jh|Sh56B*CJOJQJU^JaJphh|ShCJOJQJaJhCJOJQJaJh>j|h|Sh56B*CJOJQJU^JaJph)h56B*CJOJQJ^JaJph/h|Sh56B*CJOJQJ^JaJph8jh|Sh56B*CJOJQJU^JaJph>jh|Sh56B*CJOJQJU^JaJph[l``` dh$Ifgdkd$$IflF, `'q  t0(6    44 laytsuxy<FMTUVҵҕґq]K]95+h-OJQJaJhz#hzhz6CJOJQJ^JaJ#h-hz6CJOJQJ^JaJ&h-hz56CJOJQJ^JaJ h-hzCJOJQJ^JaJhzhzCJOJQJaJh>jh|Sh56B*CJOJQJU^JaJph8jh|Sh56B*CJOJQJU^JaJph/h|Sh56B*CJOJQJ^JaJph)h56B*CJOJQJ^JaJphYlg==* & F$d%d&d'dNOPQgdzgd,kd$$IfleF, `'q  t0(6    44 laytY;<TUVTTTTTTTTT T!Tgd-gdz)$$d%d&d'dNOPQa$gdz-$ & F$d%d&d'dNOPQa$gdz.WkTTTTTTTTTT T!TϤ򓋇hSjhSUhzh-CJOJQJaJU$h(lh-0JCJOJQJ^JaJ/jLh(lh-CJOJQJU^JaJ#jh-CJOJQJU^JaJ hzh-CJOJQJ^JaJh-CJOJQJ^JaJ, London, WC1E 6BT     4&P 1h/R . A!n"n#$% vDText22$$If!vh55T5$ #v#vT#v$ :V l t 6`H04)55T5$ yt-vDText20vDText23vDText21A$$If!vh55 55$ 55T#v#v #v#v$ #v#vT:V l t 6`H04)55 55$ 55Tp<yt-vDText26vDText27$$If!vh5B55R 5r50#vB#v#vR #vr#v0:V l t 6`H04)5B55R 5r50yt-vDText19vDText28$$If!vh5B55R 5r50#vB#v#vR #vr#v0:V l t 6`H04)5B55R 5r50yt-vDeCheck15vDeCheck15$$If!vh55q 5#v#vq #v:Vl t0(655q 5aytvDeCheck15vDeCheck15$$If!vh55q 5#v#vq #v:Vl t0(655q 5aytvDeCheck15vDeCheck15$$If!vh55q 5#v#vq #v:Vl t0(655q 5aytvDeCheck15vDeCheck15$$If!vh55q 5#v#vq #v:Vl t0(655q 5aytvDeCheck15vDeCheck15$$If!vh55q 5#v#vq #v:Vl1 t0(655q 5aytvDeCheck15vDeCheck15$$If!vh55q 5#v#vq #v:Vl1 t0(655q 5aytvDeCheck15vDeCheck15$$If!vh55q 5#v#vq #v:Vl t0(655q 5aytvDeCheck15vDeCheck15$$If!vh55q 5#v#vq #v:Vl t0(655q 5aytvDeCheck15vDeCheck15$$If!vh55q 5#v#vq #v:Vle t0(655q 5aytDyK ohsadmin@ucl.ac.ukyK Lmailto:ohsadmin@ucl.ac.ukyX;H,]ą'c@@@ ,NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No List`O` ,Titling Line 1d]5;CJOJQJaJtH <O< ,Titling Line 256U@6 , Hyperlink >*B*phj@#j |S Table Grid7:V0HQ@2H z Body Text 3$a$CJOJQJ^J V @00  <=>?kl (>EYZjq>?B014y8ghkZ[Y ; < T U V       0@0@0@0@0@0@0@00@0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 0 0 0@0@0@0@0000000000000000 <=>?kl (>EYZjq>?B014y8ghkZ[Y ; < T U V  @0@0@0@0@0@0@0@0@0@0 @0@0@0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0 @0@0 @0 @0 @0 @0 @0 @0@0@0@0@0 @0@0@0 @0@0@0@0 @0 @0@0@0 @0 @0@0@0 @0 @0@0@0 @0 @0@0@0 @0 @0@0@0 @0 @0@0@0 @0 @ 0@ 0n0s00s0@ 0n@ 0n@0n@ 0  l gms!T !#%( D ~ 0gY!T  "$&' T  (4:EQWq}#,<.}<LUe^nw_ox  FFFFFFFFG$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$X8 @& 4&(     BDCx DEF" x 0,x 0,x ,T ,T +- + +++{+M++W,W,,,;,_-m--!-!-:-V-s------....$.p(._/.;/./.W/W////M/u/k/]/N/ =/" '/; /T /T .x 0x 0x 0_ 0J 01 0 0q0N050_#00000W 0*0<0Q0~j0I0000.1~c1a1L1>23_20_20202:3IT3Z3w33"4"4A4 Z4)p4I4iW3W3I3;3&332l2^2W2L2I2Bm2Bm2BQ2E82I"2P 2W1l1~1~1111 1-1M1{1{1111-1F1_1t111212Q2m2m22222223t03TB34T3 44l4S474 4; 4; 3[ 3x 5x 5Wr6Wr6C8C8x Dx DZ\@`#" z .P  C  3"t  s *X99? "`.P   `BCKDEF !!+++++555559 G G K KKmKmKtKtKxG|9|9|5555++++DH@`Zl  0BCDElFv [[  @`( Dl  0BCDElFv [[  @` l  0BCDElFv [[  @` l   0B CDElFv [[          @`h l   0B CDElFv [[          @`( Hl   0BCDElFv [[  @` t   8BCDEpFz vggYRuGuGqDj@j@j@j@j=j=j=j=n=n9n9j6j6g6g6g6g6g2g2g2ggggggggggggggggggggggggcc\ \ \\\\\\\\\\XXXXXXXXXXXUUU U NNNNNNNNNNNNNNNNNNNNNNNNNN2N2N2N2N6N6J6J6G6G6G9G=G=G=G=J=J=J@J@G@G@CD@G@G.R#Yggv XX@`>   BC@DE4F> $ x x  $$@@$$ @`aB S  ?  3t)it@Text22Text20Text23Text21Text26Text27Text19Text28 )Fr ;X a%Yb%L0c%Ϧd%|؋e%<:f%Rg%Dh%i%tj%$k%(l%um%mn%ĕ 6GQ]g*        7HR^h+       :*urn:schemas-microsoft-com:office:smarttagsStreet>*urn:schemas-microsoft-com:office:smarttags PostalCode8*urn:schemas-microsoft-com:office:smarttagsCity> *urn:schemas-microsoft-com:office:smarttags PersonName;*urn:schemas-microsoft-com:office:smarttagsaddress?*urn:schemas-microsoft-com:office:smarttags stockticker P           ?j           33OOPP              /vܕ@^`. / |F @^`.P! ^`hH.|" pLp^p`LhH.# @ @ ^@ `hH.D$ ^`hH.% L^`LhH. & ^`hH.p' ^`hH.( PLP^P`LhH.d[hzMJA*z@,d s v  01 R}D'HH(K|QZk z _d!"$)"p#.<%(s3(Z)~) *)+0+M+\+i+u+8-m/05"156l8f8fH;"<B=2q?1l@M@ABaBe!DnE|7FgWF~F IRI~I$K=N\ OHOx QcRZU0[j^[a-brHbqeIfe@f\Jf6}fKgbg k5ym:*oUppeq>s?\sifvPw"AzDz!{|2|ld~2=:{/e(PLlZ! N3nWWP Q\^mSyD!(t @9V 'e*, N-BLE%ZXSr_-=Ljs^dMAgNW ,i-aoi2mib)&kY/O0 }1R&Mr-J,?B)]\~T|S~rbjp;K"}N*+@1Wdj7;s4[?l (>EYZjq>?B014y8ghkZ[k  Uy03FC@ (@  P@P P P@P@UnknownGz Times New Roman5Symbol3& z Arial7&{ @Calibri"1h;F L^ L^S!n4d :qHX ?,"*UCL HUMAN RESOURCES DIVISIONuczumlaUCL Oh+'0   @ L Xdlt| UCL HUMAN RESOURCES DIVISIONuczumla Normal.dotUCL4Microsoft Office Word@ @.i%@ a.1 ՜.+,D՜.+,L hp  UCL MSD^L ' UCL HUMAN RESOURCES DIVISION Title 8@ _PID_HLINKSAlh<mailto:ohsadmin@ucl.ac.uk  !"#$%&'()*+-./012345679:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcefghijkmnopqrsvRoot Entry F@91xData ,31Table8XVWordDocument6VSummaryInformation(dDocumentSummaryInformation8lCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q