Quality Management System Issue No: 13

Issue Date: TBC

RULLION ENGINEERING PERSONNEL

TEMPORARY WORKER HEALTH ASSESSMENT

The purpose of this form is to assess your suitability for placements that may arise, and ensure you are fit for relevant placements, as required under current
legislation. The Working Time Regulations are intended to protect workers from the risks that arise out of working excessively long hours or for long periods without
breaks.
Name: Address: Date of Birth:
GP Address & Tel No. Next of Kin & Tel No. What type of work do you do?
Do you suffer, or have you ever received treatment for any of the following?
Stomach Ulcer/Hernia/Persistent Indigestion or Other
Heart Condition/Palpitations/Angina/Rheumatic Fever NO NO Have you ever had a serious accident or operation? NO
Stomach Disorder
Are you currently receiving medical treatment or taking
High/Low Blood Pressure/Thrombosis/Anaemia NO Persistent Diarrhea/Colitis/Crohns Disease NO regular medication prescribed by a GP/Specialist? If so NO
please provide details.
Any chronic virus infection/Hepatitis/Jaundice NO Bladder/Kidney or Urinary Disorder NO Do you have any Disability or are you registered disabled? NO
Repetitive Strain Injury/Carpel Tunnel
Tuberculosis/Pneumonia NO NO Please provide details of any immunisations NO
Syndrome/Whole of Body Vibration
Back, Neck, Shoulder, Arm, Hand Muscle or Joint
Bronchitis/Asthma/Breathlessness/Repeated Lung or Chest Have you had any periods of self-certified or statutory sick List
NO Disorders inc. Arthritis/Rheumatism/Restricted NO
Infections or Disease pay in the last 2 years? If so how many? Separately
Movement
Do you drink alcohol? If so how many units per week? (1
Allergies i.e. Nuts/Hayfever/Rhinitis NO Nervous Disorder/Depression/Stress/Anxiety NO unit = ½ pint beer/cider/lager or 1 small glass wine or 1 NO
measure of spirits)
Other Mental or Psychological Disorder i.e.
Eczema, Dermatitis or other Skin Conditions NO NO Do you smoke? If so, how many cigarettes/cigars per day? 10 YES
Phobias/Eating Disorders/Schizophrenia etc.
Hearing Disorder or discharge from either ear NO Epilepsy/Fits/Fainting/Blackouts/Dizziness/Vertigo NO Do you have any drug or alcohol related conditions NO
Have you made any recent claims or do you have any
Loss of Vision/Serious defect in either eye NO Recurrent Headaches/Migraine NO NO
pending claims for personal injury with ay insurers?
Do you know of any reason why you should not be left to
Colour Blindness NO Head Injury/Concussion NO NO
work alone in a safety critical area
Do you know of any reason why you should not work on a
Diabetes or Gland Disorders (i.e. Adrenal/Thyroid) NO Any other Medical Condition NO NO
regular basis during the night? **
If you answered ‘yes’ to any of the above, please provide brief details on a separate sheet: ** = Only relevant where night work is a possibility
Rullion is under no obligation to offer you work and you are under no obligation to accept work. The decision to allocate night work is at the absolute discretion of Rullion Ltd. Any false
declaration will result in termination of contract.
I have completed the above form truthfully. I have read the attached explanatory information. I understand the implications of the Working Time Regulations and agree to abide by them.
In accordance with Data Protection Regulations, I agree to Rullion holding my health information on file and forwarding a copy of this form to the Client, for the purposes of them
assessing if any of the information detailed could affect my health and safety or that of others in the workplace. I agree to keep Rullion informed of any changes in my health.
Signed: S MAGUIRE Name: STEPHEN MAGUIRE Date:17/11/10

TO BE COMPLETED BY RULLION PERSONNEL - (If there are any health issues highlighted on this form Is this person fit and suitable for the type of work the requested? YES NO
please consult the SHE Manager/H&S Reps for guidance)
Is this person a YOUNG YES NO Suitable for night work contracts? YES NO If you answered NO for night work or re. fitness and suitability, outline reasons below.
WORKER? (Young workers must not be allocated
night work)
Signed: Position:
REP/QA/057 v2
Quality Management System Issue No: 13
Issue Date: 1 Oct 09
RULLION ENGINEERING PERSONNEL LTD
Health Assessment Form
To help Rullion comply with current health and safety legislation and the Working Time Regulations, all potential
temporary workers are asked to complete the attached Health Assessment Form. This is to ensure that Rullion
is able to place you in work that will be suitable for you and that will not be a potential risk to your health or well
being and that of those working with you. In accordance with the Data Protection Act, Rullion does require your
permission to hold personal information on file and to share it with clients requiring your services. This
information will be held in accordance with our Uses Of Data Statement available from our Branches or on the
Rullion Website.

The Working Time Regulations (WTR) have been implemented to protect workers from the risks associated with
working excessively long hours or for long periods without breaks. Under these Regulations, all workers are
entitled to a maximum working week of 48 hours, which is calculated by averaging the hours worked over a 17-
week period. (Individuals can decide to work longer hours if they wish, by signing an opt-out agreement).
Working time does not include travelling time between work and home, lunch breaks or rest periods. The spirit
of the WTR is to ensure all workers have suitable rest periods to avoid excessive fatigue and lack of
social/family time, which can contribute to accidents and ill health in the workplace.

Mobile Workers – A mobile worker is anyone on travelling duties (i.e. drivers/crew/trainees) where the
undertaking provides road transport services for passengers or the movement of goods. i.e. any travelling
worker involved in haulage or passenger transport. Mobile workers are bound by the WTR average working
week of 48-hours, however they may not work more than 60-hours in any single week and may not undertake
more than 10-hours night work in any 24-hour period. Mobile workers may not opt-out from these Regulations
and working time records must be maintained for 2 years. Where a mobile worker works for more than one
organisation, then the weekly working time is the working time performed for all organisations. Rest breaks and
rest periods for mobile workers are specifically defined by the Regulations. For detailed information refer to the
Department of Transport guidance at www.dft.gov.uk.

Night work - Under these Regulations, night workers are protected by further restrictions on the number of hours
they can work. These are detailed below:

• Night workers must not do more than 8 hours night work in every 24-hour period, which, again, is
averaged over a 17-week period. This means that there may be some nights during an averaging period
where more than 8 hours are worked. This is not a problem so long as the average over 17 weeks does
not exceed 8 hours per night.
• One important exception to this 8-hour rule is where night work involves special hazards or heavy
mental/physical strain. Where this applies, the flexibility allowed by the averaging period does not apply
and night work must not exceed 8 hours in every 24.
• Undertaking night work can have a detrimental effect on a worker’s performance and health. Before
being assigned to night work, all workers are entitled to a health assessment (capacities assessments
in the case of young workers) to make sure they are fit to undertake night work. Anyone undertaking
regular night work is then entitled to free assessments at regular intervals thereafter. The Health
Assessment Form meets this requirement.

Young Workers -The Regulations include a general ban on night working by young people (i.e. those aged
between the minimum school leaving age and 18 years).

• Young workers cannot work between the hours of midnight and 4am, unless this involves employment
in healthcare establishments, employment in connection with cultural, sporting, artistic or advertising
activities, or work in shipping, fisheries or the armed forces. Additionally, young people are prohibited
from working between 10pm and midnight, and between 4am and 7am. Again, there are exceptions to
this ban, which includes work in the retail, hotel, catering and bakery industries, agriculture and postal
services and newspaper deliveries.
• Young workers who would like to be considered for night work will be subject to a more detailed
health/capacities assessment to establish if the individual has both the physical and psychological
ability to do the work. Any young worker undertaking regular night work is then entitled to free
assessments at regular intervals thereafter. It is Rullion’s policy not to place young workers in night
work.
• Recent changes also affect the amount of time that a young person can be required to work each week.
Young workers will be limited to a maximum of 8 hours per day and 40-hours per week.
• The work to be carried out by young workers must be assessed to protect the health and safety of the
worker and to establish the extent of health and safety training to be provided.
• The Regulations also make provisions for compulsory rest periods for young workers.
Daily Rest – 12-hours consecutive rest in each 24-hour period.
Weekly Rest – 48-hour rest period each week.
Rest Breaks – if working for more than 4.5 hours, entitled to a minimum 30-minute rest break.
REP/QA/057
Rullion Engineering Personnel
Printed copies are considered to be uncontrolled