PSYCHOLOGICAL QUESTIOAIRE

WORKING AT ELEVATED POSITIONS

Name: _____________________________ID No:_________________________________

Have you worked at elevated positions before YES NO

1. For whom________________where_________________Height____________________
How long_________________ Type of work_______________________

2. For whom________________where_________________Height____________________
How long_________________ Type of work_______________________

Have you ever suffered from acrophobia ( Fear of Heights) YES NO

If YES describe briefly

_________________________________________________________________________________
_________________________________________________________________________________

Are you prepared to work in elevated positions ? (On and off scaffolds) YES NO

How high are you prepared to work ? ____________________________(meters)

Are you prepared to wear safety harnesses:
YES NO
Are you prepared to comply with all fall arrest procedures:
YES NO

Agreement:

1. I hereby give permission to COLMAN TUNNELING Management to enquire from the institution
holding my physical examination record to determine if there is any condition that might affect
my safety when working at elevated positions.
2. I hereby confirm that the above information given is true.

EMPLOYEE:___________________________________ DATE:____________________
COLMAN TUNNELING:____________ ___________________ DATE:____________________