Volunteer Personal Details & Medical Enquiry

STRICTLY PRIVATE AND CONFIDENTIAL

The RSPCA is committed to equality, diversity and keeping you safe. Please complete the following questionnaire below to ensure the proposed volunteer role does not pose any risk to your health.

Full Name *

Telephone Number *

Emergency Contact

In case of emergency, who would we need to contact?

Name of Emergency Contact *

Emergency Contact Address *

Emergency Contact Telephone Number *

Thank you providing us with your emergency contact information.

Volunteer Medical Enquiry

Do you have any condition which may affect any of the proposed activities?

Standing *

Walking *

Lifting/Carrying *

Seeing *

Hearing *

Climbing Stairs *

Handling disinfectant *

Handling Animals *

Do you have any allergies? *

Please provide more information *

For bird/small animals volunteers only

Shortness of breath, weezing, troublesome bouts of coughing

Regular cough or production of phlem

Bronchitis

Asthma

Any other lung disorder

Do you smoke?

Disability Disclosure

RSPCA Doncaster and Rotherham has a Disability Disclosure policy and we encourage volunteers to disclose if they have a physical or mental health condition which impacts on their ability to carry out their duties, to ensure that the appropriate support is given. this may include making responsible adjustments to enable volunteers to carry out a role and we will consider individual requests for reasonable adjustments on a case by case basis. Please tell us of any disabilities that you would consider yourself having.

Disability Disclosure

If you have selected any of the above, please provide more information.

Tetanus

In view of this everyone should be vaccinated to prevent infection. It is a requirement that all RSPCA staff and volunteers must be suitably protected.

Tetanus vaccination is carried out in infancy (3 doses), at pre-school stage and in adolescence so everyone should have had 5 doses by the time adulthood is reached. This is considered to give lifelong protection although a booster might be considered if an ijury is deemed to be high risk.

Volunteers must check their vaccination history with their GP's and if fully immunised the no further action is required. If a volunteer has not had the required doses, the GP should offer them free of charge as part of the UK vaccination schedule.

I can confirm that I am protected against Tetanus

Declaration

Please complete the following statement. I have read and understood the above and understand that I should be protected against tetanus.

I confirm

Signed

Date