Appendix 2 – Driver Questionnaire



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DRIVING AT WORK – DECLARATION FORM
1 Named Driver to complete

Name:





I confirm that I am medically fit to drive as described by the DVLA medical rules on driving (this includes having an eyesight test and the use of prescription glasses if required)
I declare that, if using a private vehicle, it is maintained in a roadworthy condition and in accordance with manufacturer’s instructions. See checklist below.
I have read and understood the Driving at Work Policy and agree to abide by its terms.

Signature:



Date:



2 Fleet Manager to complete

Name:





I have inspected the UK driver’s licence of the driver named above and can confirm that he/she is eligible to drive a designated vehicle(s)

YES / NO


I have received confirmation from Occupational Health that the named driver is fit to drive (category 1 drivers only)

YES / NO


Use of Private Vehicles on University Business

I have inspected the insurance certificate of the driver named above.

Renewal Date: ...................

NB: Private vehicles used on University Business must be insured for business use.


YES / NO



I have inspected a copy of the Vehicle’s MOT certificate (where applicable)

Renewal Date: ...................


YES / NO


Signature:


Date:



Vehicle Checks:

Prior to use of any vehicle, a thorough check should be carried out to ensure that it is fully operational.


Things to check include: Tyres (inflation and tread depth), seat belts, windscreen and windows (visibility), washer and wipers, mirrors, foot and handbrake, lights, indicators, hazard warnings, safety of passengers, security of load, fuel level.
Once on the road, the following should also be regularly monitored:

Engine temperature, fuel level, warning lights, passenger comfort, driver fatigue.



Jan 2011
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