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RF-F09a-Medical Deficiency Assessment
RF-F09a - Medical Deficiency Assessment
Name
First
Last
Date of assessment
MM slash DD slash YYYY
Medical deficiency:
Select All
Colour Blind
Diabetes
Heart Conditions
Other (please add details below)
Other medical deficiency:
Scope of work undertaken:
Assessment of risk
Are there any tasks that we carry out that will have an effect of the individual’s ability to undertake our scope of activities?
Yes
No
Control measures
Would the deficiency cause additional hazards to the worksite?
Yes
No
Control measures
Would the deficiency cause additional hazards to the pedestrians?
Yes
No
Control measures
Would the deficiency cause additional hazards to work colleagues?
Yes
No
Control measures
Would the deficiency cause additional hazards when operating Plant?
Yes
No
Control measures
Would the deficiency cause additional hazards when operating small tools?
Yes
No
Control measures
Would the deficiency cause additional hazards when driving?
Yes
No
Control measures
Is the individual safe to undertake scope of the business activities?
Yes
No
Control measures
Is the individual aware that they need to raise concerns where they feel the deficiency held may effect safe working.
Yes
No
Control measures
Additional information
Name of person undertaking assessment:
First
Last
Comments
This field is for validation purposes and should be left unchanged.
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