OFF BASE ACTIVITIES PERMISSION/CHECKLIST FORM

PERMISSION FORM:

This part should be completed by the person organising the activity/visit and submitted to the Manager of the Home/Service or Head of the School prior to leaving.

The pre planning process will also require the inclusion of suitable Risk Assessments that include measures to control the identified risks. Knowledge of places to be visited should be considered and where necessary, pre visits should take place.

The Manager/ Head will then examine the information contained in Part 1 and, if satisfied that the request fulfils the procedural requirements, will move on to complete Part 2.

1. Name Of Person Seeking Permission:
2. Date Submitted:
3. Destination & Purpose/Nature Of The Proposed Activity/Visit:
4. Mode Of Travel:
5. Date/Time Of Departure From Base:
6. Date/Time Of Return To Base:
7. Off Base Activity Risk Assessments Completed & Attached. Tick YES or NO. If No, they must be submitted prior to permission being given for the activity/visit): / YES / NO
8. Proposed Accommodation:
9. Estimated Date/Time Of Arrival At Accommodation:
10.Estimated Date/Time Of Departure From Accommodation:

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Service Users Details:

The following table is for use to indicate the details of the service users who will be participating in the activity/visit. This sheet should be photocopied if there is not enough space to enter all of the relevant details.

Name / Age / Information Re Needs / Next Of Kin / Next Of Kin Address / Tel No.

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Employee/Volunteer Details:

The following table is for use to indicate the details of the employees/volunteers who will be participating in the activity/visit. This sheet should be photocopied if there is not enough space to enter all of the relevant details. A completed copy of both the service users details and employee/volunteer details should always be left at base.

Name / First Aid Qualified / Information Re Needs / Address / Tel No / Emergency Contact Person / Tel No

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CHECKLIST FORM:

To be completed by the Manager/Head together with the Group Leader, prior to permission being given for the activity/visit to take place.

Prior to completing the following Checklist both the Manager/Head and the Group Leader will need to have familiarised themselves with the relevant Procedures

In the case of trips Abroad/ Not Within UK Mainland. A copy of Part 1 & 2 of this form should be given to and signed by the relevant Director (Schools), Assistant Director (Children’s & Young Peoples Services) or Service Manager (Adults & Older Peoples Services) before the visit can take place.

1. Name of the Group Leader
2. Name of Assistant Group Leader
3. Name of Base Contact Person & does this person have full details of the trip and all participants? / Yes / No
4. a.) Name of First Aider/s?
b.) Do they possess a current First Aid qualification appropriate to the activity/terrain where the event is to take place?
c.) Is a suitable and checked First Aid kit available to him/her?
5. Name/s of Authorised Vehicle Drivers during activity/visit
6. Do all of these people possess Full Current Driving Licences which do not expire before the vehicle returns to its base? If NO, then they cannot be Authorised. / YES / NO

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7. Is the Gender Mix of employees & service users in line with the Procedure requirements? If not please note reasons. / YES / NO
8. Is the Ratio of employees to service users in line with the Procedure requirements? If not please note reasons. / YES / NO
9.Have Off Base Activity Risk Assessments been submitted? If no they must be completed prior to permission being given / YES / NO
10. a.) If activities are due to take place, have the Group Leader or Instructors qualifications been checked & verified?
b.) Children’s Homes that do not come within the remit of an Educational Establishment (DOE), need to check whether an Adventure Activities Licensing Authority licence is required for the planned activities e.g., climbing, caving, trekking & watersports.
c.) Is special clothing required for the activities?
11.What is the planned mode of transport?
12. If using a motor vehicle, is the Road Tax Licence properly affixed to vehicle and does it cover the vehicle for the duration of the activity/visit? Additionally, is there a current MOT? / YES / NO
13. Does the Nominated Driver fulfil both Legal and Insurance requirements? Licence & Insurance checks may be necessary.
14. Vehicle Safety & Documentation:
a. Is the Vehicle Handbook in the vehicle? / YES / NO / N/A
b. Is the Orange Badge in the vehicle?
c. Is a charged Fire Extinguisher affixed in the vehicle?
d. Is there a suitable First Aid Kit in the vehicle?
e. Is a roadworthy Spare Tyre in the vehicle?
f. Are there spare Lamps, Fuses & a Torch in vehicle?
g. Is there a Red Warning Triangle in the vehicle?
h. Does the Driver have the AA membership number?
i. Has the International Motor Insurance Certificate (Green Card) been obtained and signed by the insured driver?

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j. If going abroad, has a Letter Of Authority been obtained from the registered owner to drive the vehicle? / YES / NO / N/A
k. If going abroad, has the driver obtained a copy of the European Accident Statement Form (provided by insurer)?
l. If going abroad, has a “Breakdown Cover Policy” been taken out in addition to the fleet wide cover that already exists?
m. If going abroad, is the Tachograph fitted and accurately calibrated?
n. If going abroad, are the vehicles Headlamps shaded or coloured to fulfil the requirements of the host country?
o. If going abroad, has the GB plate been properly attached to the vehicle?
15. Personal/Group Insurance: / YES / NO
a. Are all of the members of the group covered by an activity appropriate Insurance Policy?
b.What is the name and address of the company?
c. What is the Policy Number?
d. If going abroad, does the policy have a Europe Assistance Facility which includes multilingual assistance & repatriation? / YES / NO
e. If going abroad, does the policy provide cover for the early return of individual group members, in case of emergency or other difficulties?
f. If going abroad in Europe, have signed/stamped EHIC cards been obtained for each member of the group so that they can obtain emergency medical treatment?
16. Has all of the necessary permission been granted for the service users to participate in the activity/visit? / YES / NO
17.a.) Has the Group Leader provided an itinerary of proposed activities/visits?
b.) Are all staff and volunteers aware of emergency procedures?

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18. If staying away for a night or longer:
a). Has the Group Leader been issued with a Daily Log to record all significant events?
b).Have arrangements been made to provide monies in case of emergency? Please state the arrangements and amount: / YES / NO
YES / NO
19. If going abroad, have the Passport & Visa requirements been fulfilled? / YES / NO
20. If going abroad, has the agreement of the relevant Director (Schools), Assistant Director (Children’s & Young People’s Services) or Service Manager (Adults & Older Peoples Services) been obtained by sending a copy of the Form & Checklist for signing? / YES / NO
WHEN?

Note

a.)Any last minute changes to the list of participants or information contained within the Permission and Checklist Forms should be brought to the attention of the Manager/ Head and their line manager before the activity/trip commences.

b.)Group Leaders who plan to take/use equipment must also prepare and attach a copy of the Equipment Checklist.

SIGNATURES:

Group Leader & Assistant Group Leader

I have read and understood Nugent’s Policy and Procedures re Activities/Away Visits. Furthermore, I will undertake to fulfil all of the requirements to the best of my ability.

Group Leader ……………………………….. Date…………………….

Assistant Group Leader…………………………. Date………………….

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Manager Of Home/Service or Head Of School

I have read and understood Nugent’s Policy and Procedure re Activities/Away Visits. The Group leader has submitted all of the required information and I am satisfied that the arrangements for this activity/visit have been made in accordance with the required Procedures. Therefore, I give my permission for it to take place.

Manager/Head…………………………………….. Date…………………

Overnight Trips & Visits Abroad:

Director (Schools), Assistant Director (Children’s & Young People’s Services) or Service Manager (Adults & Older Peoples Services)

I have read and understood Nugent’s Policy and Procedure re Activities/Away Visits. The Head/Manager has submitted a copy of the Permission & Checklist Form and I am satisfied that the arrangements for this activity/visit have been made in accordance with the required Procedures. Therefore, I give my permission for it to take place.

Director/ Assistant Director/Service Manager:…………………………………

Date…………………….…

Note

The Assistant Director and Service Managers must always ensure that the Director of Operations is aware of all Overnight Trips & Visits Abroad before they are agreed.

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