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PRE-TRAINING HEALTH SCREEN
This document is for use at GSA training courses and update sessions.
Please complete this confidential questionnaire designed to help us, and you, identify any areas of your
health which may influence your ability to safely take part in GSA physical intervention/restraint and
breakaway physical skills training.
This training is designed to be accessed by people of a wide range of ages, weight, co-ordination and
levels of physical fitness. It is designed to ensure that you will be able to carry out the day to day training
requirements more safely.
If you are concerned about any aspect of your health in the context of physical skills training, we
recommend that you seek advice from your GP or Occupational Health Department prior to attending
physical skills training.
Please discuss any concerns you may have with your health on completion of this form with the course
tutor prior to the course commencement or on the day of training prior to the course.
Failure to declare injuries or pre course medical conditions places the responsibility on the participant
and not the training faculty.
All questions must be answered.
If yes, please explain. Include any medication
management and how this influences your daily life.
Yes
No
Yes
No
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Yes
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
No
No
Yes
No
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Yes
No
Yes
No
If so please explain:
Yes
No
If so please explain:
Yes
No
If so please explain:
Yes
No
If so please explain:
Yes
No
If so please explain:
Yes
No
Yes
No
I have read and understood the above information and have completed this questionnaire honestly and
accurately.
I am aware that GSA physical intervention / restraint and breakaway training has a physical element and
agree that, to my knowledge, I am physically able to participate in the training provided.
I understand that it is my responsibility to inform the tutors of any change in my health status prior to
attending or during physical intervention / restraint or breakaway physical skills training.
Name (in capitals):
Date of Birth:
Signed:
Date:
Signed:
Date:
Tutor Name:
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