Applicants Name: / Date: / Job Title:
Current/Former Employer: / Location/ Depot:
  1. Permission to Provide Information on Individual Safety Performance

The following information is required to establish your safety of the line record, previous history and current competence and will assist in the formation of assessment and any training plans.

For GBRf to consider your suitability for employment the information outlined in section 2 to 4 inclusive of this document is required.

An employer is not entitled to disclose information about an employee unless the employer is under a legal obligation to do so or the individual concerned has given his consent. Subject to your consent, an existing or former employer will be requested to confirm the accuracy of the information provided. Therefore, please sign below to indicate that you are in agreement for this information to be sent to your current/former employer for verification.

If you fail to provide details, or the accuracy of the information is incorrect your application will not be progressed. If it is subsequently found that you have provided inaccurate details, you will be liable to summary dismissal.

I hereby give my permission for my current and/or former employers to confirm the information in supporting records, they may hold and to provide GBRf with a copy in the event of my appointment. I understand that these records will then form part of my ‘service’ history with GBRf.

Signed ……………………………………………..Date ……………………………….

Applicant to complete all sections.

If unable to confirm any information this must be stated as ‘Unable to confirm’.

  1. Psychometric Assessments

2.1 / Psychometric assessment previously undertaken for train driving? (Y/N) / Confirmed By Employer (Y/N)
2.2 / Results of Assessments? / (Pass/Fail or N/A)
  1. Training and Competence Record

3.1 / Confirmed competent as a driver? / Date initially certified by employer
3.2 / Date completed and passed last Safety critical re-assessment? / Confirmed by employer
3.3 / Confirmed MP12, schedule 2, driver 2000 other including duration / Driver training course attended?
Confirmed by employer?
Additional comments if required:
  1. Safety Record

For the purpose of this form, safety performance is a record of the safety and operation incidents in which the individual has been involved in during their previous employment as a train driver or in any other safety critical post. This includes incidents where the individual was found to be fully or partially at fault, whether or not formal disciplinary action was taken.

4.1SPADs(tick if done)

Date / Category and Severity (if known) / Details / Confirmed

4.2Excess speed incidents, station overruns/failure to calls:(tick if done)

Date / Type of Incident / Details / Confirmed
4.3 / Other safety incidents as a driver or in other safety critical railways positions: / (tick if done)
Date / Category and Severity (if known) / Details / Confirmed

4.4Specifically Monitored Driver Rating:

Have you ever been placed on the Specially Monitored Driver register? If so, provide details:
4.5 / Have you been previously removed from safety critical duties (e.g. driving) on a temporary or permanent basis as a result of a safety of the line incident? / (Yes/No)

4.6 Other Information

Other relevant information on fitness, competence and safety performance (if necessary, attach further information):

4.7 TDLC Train Driver License

Do you have a validORR Drivers Licence?

Yes / No / *If yes please attach a colour copy
Valid From
Date of Expiry
Card Number

Staff in Confidence : Application for Employment

Name of Applicant:…………………………………………………………………………….
Position in Company:…………………………………………………………………………….
Dates of Employment:from: ……………………………. to: ……………………………….…..
Why did the applicant leave your employment? …………………………………………………..

What is your assessment of his / her:

Excellent / Good / Fair / Poor
Quality of work
Quantity of work
Application to job
Work without supervision
Relation with others / Co-operativeness
Attendance / punctuality
Honesty
Sobriety
Appearance

Do you know of any reason why we should not employ him / her:Yes / No

Details:

Would you re-employ him / her?Yes / No

If not, why not?

To the best of my knowledge the above answers are correct.

Signature:………………… Name…………………………..……………(Block capitals)

Position:……………………….…………………..Date: …………………………..

Address: …………………………………………………………………………………………………………

…….…………………………………………………………………………………………………

Contact Tel: ………………………………..