PF 012.2 Track Visitors Permit - Medical Self Certification PF 012.2 Track Visitors Permit - Medical Self Certification This Form Must Be Completed Prior to issuing a TVP in accordance with Rail Standard: NR/L2/OHS/20 Access to Work Sites Where Full Medical Examination is Not Required Go to top Date of Application * Name of the person completing this Self Certification (Should Be The Person who the TVP is being issued to) * Name of the person completing this Self Certification (Should Be The Person who the TVP is being issued to) First First Last Last Address * Address Address Address City City County County Postal Code Postal Code Address Employer * National Insurance Number * Date of Birth * Alertness and reasonable physical fitness are essential for duties, which may interact with moving trains. It is therefore important to be accurate with your answers to this questionnaire, although trivial matters should be ignored (e.g. transient dizziness while gardening two years ago). When you declare NO you are accepting a degree of responsibility for your safety. Go to top PF 012.2 Track Visitors Permit - Medical Self Certification Do you suffer from blood pressure problems (high or low) that are not controlled by medication? * Yes No Do you presently suffer depression, anxiety, panic attacks or other stress related illness requiring medication or other form of treatment? * Yes No Do you suffer from diabetes controlled on insulin or sulphonureas tablets? * Yes No Do you suffer from Epilepsy or Fits? * Yes No Have you ever had Blackouts, recurrent dizziness or any condition which may cause sudden collapse or incapacity? * Yes No Do you get discomfort or pain in the chest or shortness of breath on exercise e.g. climbing a single flight of stairs? * Yes No Do you have difficulty in moving rapidly over short distances, including on slopes, steps or rough ground? * Yes No Would you have difficulty looking over either shoulder? * Yes No Do you have any difficulty with your eyesight (other than wearing glasses or contact lenses where required)? * Yes No Do you have difficulty hearing normal conversations? * Yes No Do you have any medical condition which causes you to have excessive daytime sleepiness? * Yes No Are you taking any medication that is giving you dizziness or drowsiness? * Yes No Have you used any drug of abuse (not alcohol or tobacco) within the last 12 months? * Yes No Have you been treated for alcohol related problems or been advised by a medical practitioner to reduce your alcohol intake within the last 12 months? * Yes No Have you been treated for drug related problems within the last 12 months? * Yes No Question Check (Tick which is applicable) * Yes - One or more of the above applies to me No - None of the above applies to me Name * Name First First Last Last You have answered YES to One or more questions, Please Provide More Information * Signature * signature keyboard Clear If you are human, leave this field blank. Submit
