Health in the Field

SwanseaUniversity

Health in the Field

Declaration of Fitness to Attend

for Participating Staff and Students

Your safety and that of others is paramount

Please read the following carefully

Pre-existing health problems

Please read the guidance notes prior to completing the declaration. If you have a pre-existing health problem needing regular or intermittent treatment, you will need to inform the Activities Organiser (usually the person in charge of the field activity/trip) before the practical/field trip.

Please note that these questions refer to your current situation and not to just your long-term health (e.g. a temporary inner ear infection may affect questions (g) and (h). Any information provided will be held confidentially and only for the duration of the practical/field trip.

Failure to declare a medical condition will result in your travel cover (if provided by the University) being declared invalid (e.g. if you were to require medical treatment for this condition whilst on the field activity, you would have to bear all costs associated with this condition personally.)

If you can answer NO to ALL of the following questions, then please sign the declaration and return to the Activities Organiser.

If you cannot answer NO, or if you are in any doubt and require clarification, do NOT sign the declaration – you must contact the Activity Organiser in the first instance.

It may be necessary for you to obtain a fitness to travel letter from your GP.

Health in the Field

Declaration of Fitness to Attend for Participating Staff and Students

IN CONFIDENCE QUESTIONNAIRE :

a.I suffer from asthma or bronchitisYES/NO

b.I am subject to fits/fainting/blackoutsYES/NO

c.I suffer allergies (food/material/medication)YES/NO

d.I suffer severe headachesYES/NO

e.I have a heart/circulatory conditionYES/NO

f.I suffer from diabetes or associated conditionYES/NO

g.I suffer from travel sickness, vertigo, agoraphobia

or other such conditionYES/NO

h.I am hard of hearing and/or partially sighted,

with no corrective measureYES/NO

i.I am currently suffering from an infectious diseaseYES/NO

j.I have ( or have recently had) and injury/joint or

muscular problem that may affect my mobilityYES/NO

k.I suffer from a mental health problem (even if

mild), e.g. depression, anxiety or eating disordersYES/NO

l.I have another illness/disability or have had

surgery in the past 6 months that may affect my

safety and/or ability to perform the activities

required on this field courseYES/NO

m. I am pregnant or have been pregnant within the last 6 monthsYES/NO

Declaration

Please sign below if you have read and understand the information given. Return this form to the Activities Organiser …………………….

(insert School / Department name) by ……………..….(insert date)

Name (please print) ……………………………………………………………

Staff/student number …………………………………………………………

I will/*will not be able to attend

Signature ……………………………………………. Date …………………..

*If you have a medical condition (or any other extenuating circumstances) where you will not be fit enough or able to participate with any of the activities described, or if you with to discuss this further, in strictest confidence, please contact Sister Cathy Anthony at Occupational Health on 01792 51304. Any information received will not be used to discriminate.

…………………………………………………………………………………………………

TO BE COMPLETED BY OCCUPATIONAL HEALTH STAFF ONLY :

I consider that ………………………………………. Is fit/unfit for the field trip to

……………………………………………………………

Vaccination requiredYES/NO (as listed below where necessary)

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

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

Signed …………………………………………………………… Date……………………………………………………