*PLEASE NOTE ALL FIELDS FOR COMPLETION ARE MANDATORY*
RETAINED DUTY SYSTEM FIREFIGHTERDECLARATION OF AVAILABILITY FORM
- Wilmslow Fire Station
Q.1.Distance from your home to the Fire Station:
______Miles (Please be as accurate as possible)
Q.2.Method by which you intend to travel:(Please tick [] appropriate box)
Additional Information
If you are employed in any non-Fire service employment you are exposed to any of the following?
Hazardous substances:YesNo
If ‘yes’ please state which substances: ______
Excessive noise levels: YesNo
Mechanical Equipment: YesNo
If ‘yes’ please state what equipment: ______
Do you drive heavy goods and/or passenger vehicles carrying more than 9 passengers as of your non-Fire Service employment? Yes No
If ‘yes’ please state: Daily driving hours _____ Weekly driving hours ____
TIMES YOU WILL BE ABLE TO RESPOND TO EMERGENCY CALLS
Q.1.Time taken to travel from home to Fire Station during “Rush Hour”:
(minutes and seconds)
MotorcycleMotorcarPedal CycleRunning
By chosen method:_____ mins _____ secs
By running:_____ mins _____ secs
Unless you are self-employed or unemployed you will need to inform your employer that you are applying to become anRetained Duty System On-Call Firefighter.
Q.2.Have you informed your employer about this application?
(Please tick [] appropriate box or boxes)
Yes
No
Self-employed
Unemployed
Q.3.Are you intending to respond to emergency calls from your normal place of work?
And does your employer support this. (Please tick [] appropriate box)
Yes
No
Q.4.Are you a shift worker?
(Please tick [] appropriate box)
Yes
No
Note:If ‘YES’ please enclose a copy of your shift pattern.
Q.5.If you are currently employed (including self-employed) how many hours per week on average do you work?
Note:This average should be calculated over a 17 week reference period.
Over a 17 week reference period my average hours worked per week =
______hours per week.
Q.6.Using the 24 hour clock please complete the tables below indicating your proposed hours of availability to the nearest ¼ hour. Eg 06.00-18.15
Declaration of Hours
WEEK 1 / WEEK 2 / WEEK 3 / WEEK 4MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
TOTALS =
WEEK 5 / WEEK 6 / WEEK 7 / WEEK 8
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
TOTALS =
DECLARATION
I the undersigned, understand that I must live or work near enough to the Fire Station in order for me to be able to respond to emergency calls when alerted within a reasonable time, and in any event my attendance at the Fire Station will not exceed the travel time as agreed by the Station Manager.
.
I also understand that when travelling to the Fire Station in response to an emergency callout, I am expected (when travelling other than by foot) to comply with the Road Traffic Act.
If I wish to change this availability I understand that I need the approval of the Chief Fire Officer and that any change to this Declaration may affect my continued employment with Cheshire Fire and Rescue Service.
I certify that I am available to attend promptly at the Fire Station in response to an emergency callout at any time during the hours of availability detailed above.
Signature: …………………………………..Name: (print) …………………….………...
Date: …… / …… / ……
Note:This section to be completed by Station Manager.
I agree that the time noted in Question 1 from the applicant’s [home] or [work location] to the Fire Station is accurate and within the agreed travel time. (Manager should refer to SIF No. XXX for more guidance on the process)
Details of agreed cover: (Please tick [] appropriate boxes)
HOURS AVAILABILITY PER WEEK / PLEASE TICK24 / 110+
23 / 100-109
22 / 90-99
21 / 80-89
20 / 70-79
19 / 60-69
18 / 50-59
This availability is accepted/rejected (Delete as applicable)
Signature: …………………………………..Name: (print) …………………….………...
Rank: ………………………………………..Date: …… / …… / ……
Please return to:HR Business Support
Headquarters
Cheshire Fire & Rescue Service
Sadler Road
WinsfordCW7 2FQ