TRACK VISITOR PERMIT APPLICATION

TRACK VISITOR PERMIT REQUEST

Track Visitor Permit Information & Disclaimer

Before you apply for a TVP (Track Visitor Permit), it is important that you understand what a TVP is, who they can be issued to, what they are for, conditions of use and, more importantly, the limitations that apply to TVPs.

If you don't understand or you are simply not sure, then it is essential that you read and have understood the Key Safety Information TVP Safety Information before applying for this TVP.

Disclaimer:

Please note that this disclaimer must be completed for each application for a TVP.

You, the applicant, must supply your name. Note that this is not the name of the person to whom the TVP is to be issued, but is the name of the person making the application.

VIEW - TVP KEY SAFETY INFORMATION

Date of Application*

Applicants Name - (Who is applying for the TVP)*

First

Last

Basic TVP Information:

Supply details of the person to whom the TVP is to be issued:

Name of person this TVP is for*

First

Last

National Insurance Number*

Date of Birth*

Email Address*

Phone Number*

Number of TVP's Required*

NOTES

Shift Start Date*

Shift Start Time *

Shift End Date*

Shift End Time*

Specify the purpose of this TVP - Purpose Of Visit*

Specify up to 4 Locations where this TVP is to be used:*

MEDICAL DECLARATION

Track Visitor Permit Application

On this form, you will be required to answer a set of medical questions concerning the individual to whom the TVP is to be issued.

If the answer to any of these questions is YES, then it will be necessary for the individual to undergo medical assessment by a Network Rail authorised medical provider.

If a medical assessment will be required, and has not yet been performed, there is no point in continuing the TVP application at this stage.

1. Do you suffer from blood pressure problems (high or low) that are not controlled by medication? *

2. Do you suffer from depression, anxiety, panic attacks or other stress-related illness requiring medication or other forms of treatment? *

3. Do you suffer from diabetes, controlled by insulin or sulphonureas tablets? *

4. Do you suffer from epilepsy or fits? *

5. Have you ever suffered or are you currently suffering from blackouts, recurrent dizziness or any condition which may cause sudden collapse, impairment of balance or co-ordination or incapacity? *

6. Do you get discomfort or pain in the chest (such as angina) or shortness of breath on exercise (e.g. climbing a single flight of stairs)? *

7. Do you suffer from any health problems that would render difficulty in moving rapidly over short distances on foot, including on slopes, steps or rough ground? *

8. Would you have difficulty in looking over either shoulder? *

9. Do you have any difficulty with your eyesight (other than wearing glasses or contact lenses where required)? *

10. Do you have any difficulty hearing normal conversation? *

11. Are you taking any medication which causes you to have excessive daytime sleepiness? *

12. Are you taking any medication which makes you drowsy or has any other side effect?*

13. Have you been treated for alcohol-related problems or been advised by a Medical Practioner to reduce your alcohol intake within the last 12 months? *

14. Have you used any drugs of abuse (not alcohol or tobacco) within the last 12 months? *

15. Have you been treated for drug-related problems within the last 12 months? *

Destination for the TVP:

If you choose to have the TVP sent to an email address, please be very careful that the email address is correct.

Email Address Of The Person Who Is To Recieve The TVP*

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TRACK VISITOR PERMIT APPLICATION

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