a) Have you been convicted of any motoring offences (including fixed penalty offences) Yes/No during the last 5 years? If so, please give details on a separate page. 7. Yes/No b) Is any prosecution pending? 8. Do you have any points on your licence? If so, please give full details on a separate page. Yes/No Do you have a medical condition that has to be notified to the DVLA? Check the links and follow guidance: 9. Yes/No If yes, please provide details separately; the University will need to inform the Insurers. Have you ever had any motor vehicle insurance you hold or have held, declined, cancelled 10. Yes/No or refused at normal terms? You are only covered to drive for University business purposes, providing you have a valid, full licence, the relevant category on the driving licence, and have disclosed any medical conditions that might affect your driving to the DVLA, and UoW Please confirm that you have read and understood the University policy for and, if relevant, the Yes/No I hereby declare that the above statement and particulars are true and that there is no pending material information that should be disclosed. I agree to advise the University immediately of any changes in particulars. I understand that I am duty to inform my line manager and the University’s Insurance Officer of any additional convictions (including penalty points), periods of disqualification or medical condition that would prevent me from driving immediately. Driver’s Signature: Date: 1 If you have not completed the University Minibus Defensive Driving Course please contact Mark White (Campus Services Supervisor) It is your responsibility to update this form annually and return it to Jude Wild in Finance We are requesting this information from you to ensure appropriate cover with University’s insurance and to allow employees to make expense claims. We may also require this information in order to facilitate car hire. For the same purpose we may provide this information about you to the University’s Insurers to ensure sufficient cover. The processing of this data is necessary for the performance of a contract between the University and the employee (Article 6 (1) 9b). Please note that the University of Worcester is the Data Controller and details of how we process your data including how long we retain it and your rights are detailed on
7. a) Have you been convicted of any motoring offences (including fixed penalty offences) during the last 5 years? If so, please give details on a separate page. b) Is any prosecution pending? Yes/No Yes/No 8. Do you have any points on your licence? If so, please give full details on a separate page. Yes/No 9. Do you have a medical condition that has to be notified to the DVLA? Check the links and follow guidance: If yes, please provide details separately; the University will need to inform the Insurers. Yes/No 10. Have you ever had any motor vehicle insurance you hold or have held, declined, cancelled or refused at normal terms? Yes/No You are only covered to drive for University business purposes, providing you have a valid, full licence, the relevant category on the driving licence, and have disclosed any medical conditions that might affect your driving to the DVLA, and UoW Please confirm that you have read and understood the University policy for and, if relevant, the Yes/No I hereby declare that the above statement and particulars are true and that there is no pending material information that should be disclosed. I agree to advise the University immediately of any changes in particulars. I understand that I am duty to inform my line manager and the University’s Insurance Officer of any additional convictions (including penalty points), periods of disqualification or medical condition that would prevent me from driving immediately. Driver’s Signature: Date: 1 If you have not completed the University Minibus Defensive Driving Course please contact Mark White (Campus Services Supervisor) It is your responsibility to update this form annually and return it to Jude Wild in Finance We are requesting this information from you to ensure appropriate cover with University’s insurance and to allow employees to make expense claims. We may also require this information in order to facilitate car hire. For the same purpose we may provide this information about you to the University’s Insurers to ensure sufficient cover. The processing of this data is necessary for the performance of a contract between the University and the employee (Article 6 (1) 9b). Please note that the University of Worcester is the Data Controller and details of how we process your data including how long we retain it and your rights are detailed on
Work_Related_Driving_Drivers_Questionnaire_July18.docx