Document No. Revision No.

Date Compiled Date of Next Review Custodians

HSE/DOC/PROC 4.5.1.5d 01 November November 2017 SHE Department
2016

Fitness to Drive/Critical Task Questionnaire

SURNAME: ___________________ INITIALS: ___________ EMPLOYEE NO: ________________

DEPARTMENT:_______________________

This questionnaire should be completed comprehensively. Please try to answer all the questions. The
information will be treated confidentially.
WARNING. You are accountable for the accuracy of your statements. If information is withheld or
deliberately misleading, you may be in contravention of the requirements specified in terms of the Road
Traffic Act (93 of 1996.) and disciplinary action may be taken against you.
Have any of the following conditions occurred on the job or off the job in the last 24 months?
Please tick either the Yes or No column as appropriate.

QUESTIONS YES NO

1. Epileptic seizure?

2. Loss of consciousness or blackout?

3. Falling asleep while driving or similar activity?

4. Any disease or condition of the brain or nervous system?

5. Attacks of dizziness or vertigo (a spinning sensation)?

6. Attack(s) of temporary, partial or complete blindness?

7. A heart attack, angina or disturbance of the pulse rate or rhythm?

8. Any other heart disease?

9. High blood pressure?

If on treatment, please list your medication plus any side effects you may be experiencing.
Name of medication and side effects
_________________________________________________________
Name of medication and side effects
_________________________________________________________

10. Diabetes?
If yes, (Circle the correct answer)
Document No. Revision No. Date Compiled Date of Next Review Custodians
HSE/DOC/PROC 4.5.1.5d 01 November November 2017 SHE Department
2016

Insulin?
Tablets?
Both?
11. Serious psychiatric or psychological illness?

12. Alcohol abuse or dependence?

13. Are you taking an anti-depressant, tranquillisers, and tablets for stress or nerves or
any other medication that could impair your response or driving ability?
If so, please list the names

13.1 _________________________________________________________
13.2 _________________________________________________________
13.3 _________________________________________________________
14. Do you use any of the illicit recreational drugs? (e.g. Dagga, Ecstasy, LSD, amphetamines or
cocaine.)
15. Any eye injury, illness or eye operation?

16. Are you suffering from any vision impairment?

17. Do you have any endorsements on your license related to your driving ability?

If the answer was yes to any of the above, please provide full details in the space below.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

__________________________________________________

DECLARATION: I certify that the above information is, to the best of my knowledge, a true and
accurate reflection.

SIGNATURE ______________________________ DATE _________________________