The Costain Way Contract Induction Record

______________________________________________________________________________

CONTRACT INDUCTION RECORD

DATE: INDUCTION RECORD No.

[Office use] [Office use]

CONTRACT: C360 Mile End DRUGS & ALCOHOL TEST: PASS / FAIL
[Office use]

Please enter your personal details.

These are kept safe and confidential and are not accessible to 3rd parties.
LUZIVAR DOS
RAMOS
1. Your FULL name (Clearly print in CAPITALS) SACRAMENTO

2. Name of your employer / company SERVEST

3. Your Date of Birth 01-11-1990

85 Blackthorn Road,
4. Your home address Ilford, IG1 2NS

5. Your address if it is different to your home

address [e.g. if you are lodging away for
work purposes]

6. The best telephone number to contact you 07424862798

on
7. Name of someone to contact in the case of
emergency e.g. partner or parent Valdmar Bolivar
8. Telephone number for your emergency
contact 07424862798
Please now complete the following questions which relate to
your ability to carry out your job safely
9. Job Role (on this contract):

10. Your competency cards: You must Card type [e.g. CSCS] Card No. & Expiry date
prove you are competent to do your
job. State your core competency CSCS 06159382- June 2023
card(s) e.g. CSCS , CCNSG, CPCS, or
other competency card, and its
expiry date
e.g. General Operative, Plant
Operator or Scaffolder.

11. Your training: State any additional

First Aid, Door
supervisor, CCTV
training certificates or ‘tickets’ you OPERATOR
hold for your job
e.g. PASMA, First Aid, Confined
Space.
SHE-T-250 Rev 3
The Costain Way Contract Induction Record

______________________________________________________________________________ 12.
Safety Critical: Is your job a ‘Safety Critical’ role?
Safety Critical = Mobile Plant Operator, Banksman, Slinger Signaller, Yes / No Traffic NO
Marshall, Tunneller/ Confined Space Worker, Road Worker,
Asbestos Worker or if you work at height without fixed
edge protection e.g. Scaffolder or Steel Erector.
13. Medical records: If you answered yes to Yes or No or N/A (please circle)
Q12, have you provided evidence of a If Yes: Date Medical completed: ___/____/____
suitable medical? [If in doubt ask] If No: You cannot work in a Safety Critical role

14. Your health and your ability to work safely

If you suffer from a disability, have a previous injury or have a health condition it may affect the
way in which you work. This may include taking medication for a condition.
Information you provide will be held in the strictest confidence and in accordance with the Data
Protection Act. It may be given to the Emergency Services if you are involved in an accident.
Do you have any previous injuries or health conditions stated below? (tick) Yes No
▪ A previous or recurring injury e.g. knee or ankle or back problems X
▪ Hearing loss / deafness X
▪ Asthma or other lung condition X
▪ Epilepsy X
▪ High blood pressure requiring medication X
▪ Diabetes X
▪ Heart condition X
▪ Dermatitis X
▪ Hand Arm Vibration Syndrome (HAVS ‐ Vibration White Finger) X
▪ Medication which may affect the way in which you work X
▪ If you have answered yes to any of the above or have any other conditions please provide
detail in this box and discuss any arrangements with the Inductor.

15. Your health – vibrating tools: Are you likely to use vibratory tools (e.g. grinders,
hammer drills, breakers, scabblers, wacker plates) to carry out your
work at this site? No
If you have answered yes to the question above you must complete a
separate Hand Arm Vibration Syndrome (HAVS) Questionnaire (SHE‐T‐249) in
addition to this induction.
16. Plant Operators: If you are a Plant Operator e.g. Excavator Driver, you
MUST inform the person in charge of this session.

Are you employed on this job as a Plant Operator? No

If you have answered yes to the question above you must complete
a separate Plant Operator’s Induction (SHE‐T‐247).
17. Supervisors: If you are employed as a Supervisor you MUST inform the
SHE-T-250 Rev 3
The Costain Way Contract Induction Record

______________________________________________________________________________
person in charge of this session.

Are you employed on this job as a Supervisor? No

If you have answered yes to the question above you must complete a
separate Supervisor/ Manager Induction (SHE‐T‐280) and Supervisor
Assessments (SHE‐T‐371).
18. Your view: Please use this space to comment on the induction, site or any other relevant matter.

19. This is a record that I have received a Familiarisation [induction] briefing for this site.
I consent to the information on this form being held and processed by the Costain Group in
the utmost confidence and in accordance with the Data Protection Act 1998.

Signed [you] Luzivar Sacramento Date: 29-06-2018

20. Name and Job Role of Briefer [inductor]

18. Briefer’s signature [Office use]

SHE-T-250 Rev 3
The Costain Way HAVS Induction Questions
______________________________________________________________________________

TO BE COMPLETED IF INDUCTEE IS LIKELY TO BE USING HAND-HELD VIBRATING TOOLS,

HAND-GUIDED VIBRATING MACHINES OR HAND-FED VIBRATING MACHINES

Date ...........................................................................................................................................

Name .........................................................................................................................................

Occupation.................................................................................................................................

Induction Number………………………………………………………………………………………..

Have you ever used hand-held vibrating tools, machines or hand-fed processes in your
job? Yes/No
IF YES:
(a)
List year of first exposure:
(b)
When was the last time you used them? (Detail work history overleaf)

1 Do you have any tingling of the fingers lasting more than 20 minutes after using Yes/No
vibrating equipment?
2 Do you have any tingling of the fingers at any other time? Yes/No
3 Do you wake at night with pain, tingling, or numbness in your hand or wrist? Yes/No
4 Does one or more of your fingers go numb more than 20 minutes after using Yes/No
vibrating equipment?
5 Have your fingers gone white* on cold exposure? Yes/No
6 If yes to 5, do you have difficulty re-warming them when leaving the cold? Yes/No
7 Do your fingers go white at any time? Yes/No
8 Are you experiencing any other problems with the muscles or joints of the hands or Yes/No
arms?
9 Do you have difficulty picking up very small objects, e.g. screws or buttons or Yes/No
opening jars?
10 Have you ever had a neck, arm or hand injury or operation? Yes/No
If so give details:

11 Have you ever had any serious diseases of the joints, skin, nerves, heart or blood Yes/No
vessels?
If so give details

SHE-T-249 Rev.1
The Costain Way HAVS Induction Questions
______________________________________________________________________________

12 Are you on any long-term medication? No

If so give details:

* Whiteness means a clear discoloration of the fingers with a sharp edge, usually followed by red flush

OCCUPATIONAL HISTORY

Date: Job Title:

SHE-T-249 Rev.1
 Crossrail Contract C360
Eleanor Street/Mile End Park Shafts

Equality Monitoring
It is important to TfL’s success that its workforce develops to reflect the diversity of its customers. In order for us to monitor
progress, we need to know the diversity of individuals working on the Main Works Contract. The information you provide
here is voluntary and confidential. If you complete this section you will be agreeing that TfL may hold this information. It
will only be used for monitoring purposes and general analysis and will not be used to make any decisions about individuals.

RESIDENCE (Which borough do you live in? please x the applicable box)

Newham Waltham Greenwich Tower Hackney Other X

Forest Hamlets

Age 17 - 25 26 - 35 X 36 - 45 46 - 55 Over 55yrs

ETHNIC GROUP (please x the applicable box):

White Black or Black British Asian or Asian British

British Black Caribbean Indian
Irish Black African X Pakistani
Any other White background Any other Black background Bangladeshi
Any other Asian background
Please specify Please specify
Please specify
Mixed
White & Black Caribbean Chinese/Other Ethnic Group
White & Black African Chinese
White & Asian Any other background
Any other Mixed background
Please specify
Please specify

FAITH
What, if any, is your faith? The categories for faith, listed below are taken from the 2001 Census. If you feel
that your faith is not represented, please detail in the ‘Other’ box. Please x one box from the list below.

Buddhist Hindu None X

Christian Muslim Prefer not to say
Jewish Sikh Other
Please specify
SEXUAL ORIENTATION
Please x the appropriate box (as many as apply). Are you a:

Lesbian Gay man Prefer not to say

Bisexual woman Bisexual man Other
Heterosexual woman Heterosexual man X
Please specify
Transgendered woman Transgendered man

LONDON LIVING WAGE

Yes
Are you paid less than the London Living Wage of £9.40* No X

*If you are paid less than £9.40 per hour please advise the inductor.

DISABILITY
The Disability Discrimination Act (1995) defines a disabled person as someone with a ‘physical or mental
impairment’ which has a substantial and long-term adverse effect on his/her ability to carry out normal day-to-day
activities.

Do you consider yourself to have a disability, as defined by the Disability Discrimination Act?

Yes
No X
DATE 29/06/2018

Thank you, if you have any concerns in relation to the questions, please contact Charlie Eve on 07799 435666