RAIL REGISTRATION FORM - 981

THIS FORM MUST BE COMPLETED INFULL BEFORE ANY WORK ASSIGNMENTS (RAILWAY SAFETY CRITICAL) COMMENCES.
OPERATIVE NAME : *
SENTINEL NO : *
Application Checklist: *

Completed Application Induction Form Contract of Sponsorship Agreement Medical Questionnaire Completed Copy of Sentinel Card Copies of Certificates, and Cards (Small tools, CSCS, CPCS etc) Proof of ID (Passport or Birth Certificate) Copy of Driving Licence (if applicable)
Attach ID

Browse Files

Cancel of

Personal Details
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State

Post Code
D.O.B

Day Month Year
Date
NI Number
Sentinel No
CSCS Card

Yes No
CSCS Card Number
CSCS Card Expiry
TEL (Home)

Area Code Phone Number
TEL (Mobile)

Area Code Phone Number
Email Address
example@example.com
Nationality
Driving Licence

Yes No
Car Owner

Yes No
Emergency Contact Details (Person to be Contacted in case of emergency)
Name

First Name Last Name
Relationship to you
Address

Street Address

Street Address Line 2

City State / Province

Postal Code
TEL (DAYTIME)

Area Code Phone Number
TEL (EVENING)

Area Code Phone Number

PROFESSIONAL REFERENCES

Referee 1

	Details
Name
Company
Position
Address
Telephone
Email
From
To

Referee 2

	Details
Name
Company
Position
Address
Telephone
Email
From
To

PROFESSIONAL QUALIFICATIONS, CERTIFICATES & CARDS
Qualification / Certificate, Awarding Body, Date Achieved, Grade Achieved

SKILLS AND EXPERIENCE
Please provide details of work you have undertaken within the railway infrastructure.
Please list the different locations and projects that you have worked on.

WORKING TIME REGULATIONS (RAILWAY SPECIFIC)
PLEASE ENSURE THAT YOU ARE FAMILIAR WITH THE FOLLOWING:
The work patterns of both Primary and Sub Sponsored staff working on railway projects will be planned such so that no-one exceeds the working hours rules:
- Shifts not to exceed 12 hours or Total hours not to exceed 72 hours per week (Saturday to Friday)
- Must not work more than 13 shifts in 14 days
- Must not have less than 12 hour rest periods between consecutive shifts
Outside these hours a 1 hour limit either side of the shift is permissible for travelling time, making allowances for a 14 hour door to door day.
Pendersons Ltd will not accept any shifts/hours which will put you in contravention of the above work patterns.
However in emergency situations, to cover essential work only and provided no alternative arrangements can be made the limits may be exceeded if authorised by the clients nominated representative on site and with the applicable records kept.
Total hours worked for Pendersons Limited and any other organisation must not cumulatively exceed the limits stated.

Working Hour disclaimer for rail working:-
1. I, the undersigned declare that I have been made aware of the requirements of the Pendersons Ltd Working Hours Policy and Arrangements and agree to adhere to their contents.
2. I also understand that it is my responsibility not to work for other organisations during the minimum rest periods as stated above.
3. I will also notify Pendersons Limited of working hours/shift patterns that will prevent me from accepting any immediate placements from them.
4. I agree not to work for Sub-sponsors until I have had confirmation from Pendersons as my Primary Sponsor
Please print name below by submitting this for you confirm that you understand the Working Time Regulations
Inductee Name (Print)
Date

SAFETY RESPONSIBILITY & SENTINEL SCHEME RULES
PLEASE ENSURE THAT YOU ARE FAMILIAR WITH THE FOLLOWING:
- You are required at all times to ensure avoidance of injury to yourself and colleagues and to minimize risk to the environment, railway infrastructure and the travelling public.
- You are expected to demonstrate a positive and enthusiastic attitude towards safety in all dealings with management, Sponsored Staff, our clients and contractors.
- You must ensure that you have been provided with adequate Personal Protective Equipment and that you wear it correctly, keep it clean and have it replaced if necessary. If you need any replacements - get in contact with Pendersons Resources.
- You are expected to carry out and participate in accident and incident investigation. Any accidents or incidents must be reported in accordance with laid down procedures. Investigation and discussion of accidents, incidents, close calls and near misses will be carried out openly and in a ‘no blame’ culture.
- You are expected to participate with relevant input in safety briefings and other team meetings.
- You must not commence work unless you have been adequately briefed on, and understand the method of work, site specific risks, local hazards and the emergency arrangements for the site. Check that emergency communication equipment is working correctly, and you receive a task briefing and Work Package Plan for all projects.
- You must use, or be briefed on, site specific method statements and risk assessments for the work you are undertaking.
- Ensure that you work to the sections of the Rule Book/ handbook applicable to the competencies you hold and the duties you are carrying out. Also ensure you have an up to date logbook. Live copies of all modules can be found on the RGS website www.rgsonline.co.uk
- Only access and egress sites by official access points. Where possible, use authorized walking routes.
- Work to the instruction of the person in charge of the work.
- Always leave sites safe and free from loose materials.
- If you wear contact lenses, ensure that you carry a pair of glasses with you at all times
- You are required to observe the Sentinel Scheme Rules at all times

Pendersons Induction Checklist
Name of Employee
Name of Briefer
Pendersons staff
Date

Day Month Year
Date
Please ensure all procedures and policies are fully understood. By ticking each box, you are confirming that you understand those policies and procedures, and agree to adhere to those at all times.
Policies, Procedures & Documents

Section A: All employees

	Confirmation	Remarks / Comments
1.1 Organisation and Structure
2.1 Health and Safety Policy
2.2 Environmental Policy
2.3 Quality Policy
2.4 Drugs and Alcohol Policy
2.5 PPE Policy – and issuing procedure
2.6 Refusal to Work Policy
2.7 Grievance Policy
2.8 Equality & Diversity Policy
2.9 Safe Guarding Policy & arrangements
2.10 General Data Protection Policy
3.1 Accidents and Incidents
4.1 Contract of sponsorship detailed & signed
5.1 Evacuation Routes Fire/ First Aid provision
5.2 Notification of Medication reporting – as P05
6.1 Appeals & Complaints Policy

Section B: All Employees undertaken duties on NWR Infrastructure

	Confirmation	Remarks / Comments
1.1 Working Hours Policy
1.2 Rail Worker Travelling Hours Policy
1.3 Rail Event Reporting Policy
1.4 Sentinel scheme rules
1.5 RTAS scheme rules
2.1 Working Hours
3.1 Rule Book
3.2 Track Safety Handbook
3.3 Briefings
3.4 Provision of Safe System of Work Pack(s)
3.5 Relevant Risk and COSHH assessments

Acceptance of Induction
By pressing the submit button at the end of this form you are confirming you have seen and understand the above policies and will adhere to them.

Spectacles and Contact Lens Register
Do you wear spectacles or contact lenses?

Yes No
If YES by submitting this form you agree to ensure that a spare pair of spectacles are kept with you when working on NWR Infrastructure.
Medication Register
Do you take any prescribed medication?

Yes No
If yes please give details below
‘I will inform Pendersons Ltd of changes to my health that will affect my ability to carry out the duties tasked to me. I further agree to notify Pendersons Ltd to any changes on the medication that I am currently on, or I am prescribed through any medical practitioner’.

Confirm you agree that
‘I will inform Pendersons Ltd of changes to my health that will affect my ability to carry out the duties tasked to me. I further agree to notify Pendersons Ltd to any changes on the medication that I am currently on, or I am prescribed through any medical practitioner’.

Confirm you agree that

PPE ISSUE
Name
Sentinel No
I confirm the following:
- To keep any PPE received in good working order
- To use it for its intended purpose
- To ensure that I will wear PPE when it is required of me
- To inform Pendersons Resources Limited and obtain replacements where needed
To confirm the above
Date

Day Month Year
PLEASE ENSURE THIS FORM IS COMPLETED EACH TIME ANY PPE IS ISSUED*

*NOTE FOR PERSON ISSUING PPE – PLEASE ENSURE THAT ANYTHING NOT LISTED, OR ADDITIONAL ITEMS ARE TO BE RECORDED IN THE SPACES PROVIDED.

**PERSON ISSUING

***PERSON RECEIVING

ITEM

	ITEM ALREADY IN POSSESSION	DATE OF ISSUE	NAME PI**	INITIAL PI**	INITIAL PR***
HV (ORANGE RAIL SPEC) VEST
HV (ORANGE RAIL SPEC) JACKET
HV (ORANGE RAIL SPEC) TROUSERS
HV (ORANGE RAIL SPEC) WATERPROOF BOTTOMS
SAFETY BOOTS
SAFETY GLASSES
CUT 5 GLOVES
EAR DEFENDERS
HELMET TORCH (NIGHT TIME WORKING)
SAFETY HELMET (BLUE)
SAFETY HELMET (WHITE)

SAFETY HELMET (BLUE) DATE OF MANUFACTURE
(PLEASE ENSURE THIS IS TAKEN FROM WITHIN THE HELMET)
SAFETY HELMET (WHITE) DATE OF MANUFACTURE
(PLEASE ENSURE THIS IS TAKEN FROM WITHIN THE HELMET)

Declaration
I have completed this Registration Form to the best of my knowledge and have not omitted any relevant details. I will notify Pendersons Ltd of any changes to my details at the earliest opportunity. I understand that I may incur criminal or civil liability for making any false statements and that, if applicable, my Contract for Services may be terminated.

Our Health & Safety Policy confirms the importance of the duty of care that is owed to you. Therefore Pendersons will take all reasonable steps to ensure your health, safety and welfare while visiting our offices and through close liaison and co-operation with the Client, as far as is reasonably practicable, while working on our Client’s premises. However, please note that the Client must provide all workers with a working environment that complies with current Health & Safety regulations and you must therefore be given the same level of protection as the Client’s permanent employees.

Furthermore it is your responsibility to ensure your own health, safety and welfare and that of others by:
- Providing accurate and relevant information and documentation prior to commencing a temporary assignment and updating Pendersons Ltd as and when this information changes
- Co-operating with the client at all times in respect of their Health & Safety policies and procedures
- Notifying both the Client and Pendersons Ltd of any Health & Safety issues at the earliest opportunity
By signing this registration form, you are deemed to have read and understood the above statement. Our full Health & Safety Policy would have been provided with your Induction and Sponsorship and is also further available on request.

I consent to Pendersons Ltd storing my personal & sensitive personal data in both written & electronic format and understand that it will be used for providing work-finding services to me. I consent to Pendersons Ltd to sharing my data with other Pendersons Ltd companies for the purposes of providing work-finding services or outsourced support functions.

I understand that:

(i) personal information and data relating to me will be processed by Pendersons Ltd and any

Pendersons group companies from time to time and any client or prospective client of Pendersons

Ltd or Pendersons group companies (in addition to Pendersons Ltd and any Pendersons group
I consent to Pendersons Ltd seeking suitable employment or engagement for me in the position which I have indicated. I understand that Pendersons Ltd will be acting as an Employment

Business when providing freelance work-finding services to me and will be acting as an

Employment Agency when providing permanent work-finding services to me. I understand that Pendersons Ltd has no obligation to find me employment or engagement and I am under no obligation to accept any offer of work.

**I am also responsible for checking the My Cloud at the start of each month to check for any updates that may affect my duties. Also on My Cloud will be any Safety Communication from Network Rail or other regulating bodies. Details of your log in details are on the last page of this Resource pack and should be removed and kept with you for your information. Log in details will be changed yearly and sent to you. You must confirm to the Resources department that you are in receipt of these Log in details**

I confirm that I have read and understood all of the information in this Registration Form, and will comply with the Contract for Services Agreement.
Full Name
Please tick to confirm (The person named is completing and submitting this form)
Date

Month Day Year
Date

Sentinel Contract of Sponsorship

Your signature below confirms that you have read, understood and will comply with the Pendersons Limited Sentinel Contract of Sponsorship, as detailed below.

This contract is required to be completed prior to sponsorship being applied for. It is used to confirm that you have the required levels of competence and that Pendersons Ltd can be assured of your suitability to work for them. Sub sponsorship is not permitted unless agreed by your line manager.

If you are representing Pendersons Limited you are required to wear a PPE with the Pendersons logo.

Pendersons Ltd as your Primary Sponsor are responsible for ensuring you:
- Have had and document a pre-sponsorship interview to determine your eligibility to work in the UK and is sufficiently able to communicate in verbal and/or written English.
- Have a ‘contract of sponsorship’ with each individual we are the Primary Sponsor for.
- Monitoring and management of working hours of Individuals. Shifts worked with Sub-Sponsors must be considered in the monitoring of working hours and the management of fatigue. This is aided by the use of the Sentinel System and Swipe Access data
- Any Sub-Sponsorship arrangements with the Individual and to grant permission to any Sub-Sponsor to use their resources
- Enacting the Investigation process where any suspected breach of the Sentinel Scheme Rules becomes apparent
- Collating information from Sub-Sponsors to enable conclusion of the Investigation
- Maintaining records of Investigations and requesting a Formal Review where a Scheme Outcome is recommended following an Investigation
- Providing a reason for de-sponsoring an Individual
- Conducting an Investigation for any alleged breach of the Sentinel Scheme Rules.
- Collating and maintaining all records associated with the Contract of Sponsorship of an Individual as required by the Sentinel Management System
- Issuing a temporary Take Down of competence pending the conclusion of an Investigation, where appropriate.
- Ensure a process is in place to manage the D&A screening process as defined in the Infrastructure Maintainers requirements
- Shall undertake checks on each individual’s suitability to work on NRMI – prior to sponsorship contract completion.
- You will need to supply evidence that you have been practicing the competencies held within the last 6 months prior to this application for sponsorship. You may be requested to provide evidence in the form of NR competence logbooks; Interview; successful completion of a questionnaire or work based evidence produced such as completed SSOWP etc.
- If you have not undertaken a competence in 6 months then Pendersons Limited are required to ensure that you have a mentored assessment. This can take the form of a PTS exam, an on-site assessment/practical exam and that those results are recorded within our management system.
- Is responsible for ensuring you receive;
  - A valid Sentinel Smart Card.
  - Induction and Regular Briefings to keep up to date with Sentinel Scheme Rules, Standards & Rule Book updates.
  - Suitable PPE marked as to identify who an Individual is working for when on the Infrastructure & suitable equipment and associated training to be able to use that protective equipment effectively.
  - Advice, guidance or instruction on restrictions (medicine or fitness).
  - Mentorship and support, where agreed, to develop competence.
  - Training and assessments to ensure competencies to undertake their duties at the required intervals.
  - Personal issue information such as handbooks and relevant information.
  - Safety Critical Equipment to enable the Individual to undertake their role (where a sponsored individual only requires Safety Critical Equipment for works undertaken for the Sub-Sponsor, then this equipment shall be provided by the Sub-Sponsor)
- Pendersons Limited as your primary sponsor and employer are required to keep you updated for the purposes of H&S legislation.
Your Individual Responsibilities:
- No Individual shall undertake or attempt to report for duty, if they have worked on the managed infrastructure within the preceding 12 hours (sometimes referred to as double-shifting), unless a risk assessment has been conducted by the Primary Sponsor and suitable controls implemented
- No Individual shall exceed the maximum working hours determined by law or the, managed infrastructure requirements or the Sponsor, whichever is the shortest
- Every Individual has a responsibility to be fit for work, not fatigued by excessive travel or work, and not under the influence of drugs or alcohol. Individuals shall report anything that may affect their ability to work safely including medication, lack of equipment or personal circumstances
- An Individual shall report for duty with the appropriate Personal Protective Equipment (PPE) to enable them to undertake their duties
- No Individual shall undertake a task for which they are not competent, do not have the right equipment, or the relevant information or the knowledge to complete safely.
- Individuals shall act in a safe manner at all times when on the managed infrastructure, and report any incident, close call or breach of the Sentinel Scheme Rules they are aware of Individuals shall always carry their Sentinel card when on managed infrastructure and present their card for checking upon request.
- Where accountable; undertaking 100% verification checks on Sentinel cards before allowing Individuals to start work.
- Providing accurate personal information to Pendersons Ltd and keeping it up to date.
- Know the identity of their Primary Sponsor
- Know which Sub-Sponsor they are working for (when they are not working for their Primary Sponsor)
- Provide the name of the Sponsor they are working for when booking into site and have identifiable PPE
- Confirm that any shift(s) for a Sub-Sponsor have been approved by their Primary Sponsor before working for the Sub-Sponsor
- It is your responsibility to keep track of any assessments required along with the expiry of any competences. A discount of 25% is given to all Pendersons Ltd sponsored persons by Pendersons Training for any initial training, assessments and recertification delivered by Pendersons Training only. Training/assessments with any provider will need to be paid directly.
This document and all other Pendersons communication aims regarding sponsorship is aimed to demonstrate their commitment to meeting this contract of Sponsorship.

Acceptance of Contract of Sponsorship
Please print name and sign below to confirm sponsorship
Sentinel Card No
Employee Name
Briefer Name
Tick to confirm acceptance of contract of sponsorship
Date

Month Day Year
Date

Log in details for My Cloud
You must check at the beginning of every month and if notified by Pendersons Ltd of any updates.

If you have problems please contact your Line Manager at Pendersons Ltd who will give you details on how to log in.

Log in to https://bit.ly/2FuZAia

Username: info@pendersons.com

Password: Sponsor1

(You need to ensure you use the Capital ‘S’ as the password is case sensitive)

DO NOT REQUEST TO CHANGE THE PASSWORD –THIS IS REGULATED BY PENDERSONS AND CANNOT BE DONE

I can confirm I am the person named on this form clicking submit.

All identification and supporting documents will be sent to info@pendersons.com

Work will not be given until all documentation is received and completed in full
Should be Empty:

	Yes	No
DO YOU HAVE DIABETES NEEDING INSULIN?
DO YOU SUFFER FROM EPILEPSY OR FITS?
HAVE YOU EVER HAD BLACKOUTS, RECURRENT DIZZINESS OR ANY CONDITION, WHICH MAY CAUSE SUDDEN COLLAPSE OR INCAPACITY?
DO YOU GET DISCOMFORT OR PAIN IN THE CHEST OR SHORTNESS OF BREATH ON NORMAL PHYSICAL ACTIVITY? EG WALKING A FLIGHT OF STAIRS
DO YOU HAVE DIFFICULTY IN MOVING RAPIDLY OVER SHORT DISTANCES, INCLUDING ON SLOPES, STEPS OR ROUGH GROUND?
WOULD YOU HAVE DIFFICULTY IN LOOKING OVER EITHER SHOULDER?
WOULD YOU HAVE DIFFICULTY WORKING IN OUT-DOOR OPEN AREAS?
WOULD YOU HAVE DIFFICULTY WORKING IN ENCLOSED SPACES?
WOULD YOU HAVE DIFFICULTY WORKING ABOVE HEAD HEIGHT?
DO YOU HAVE DIFFICULTY WITH YOUR EYESIGHT?
IF YES, DO YOU WEAR GLASSES / CONTACT LENSES?
DO YOU HAVE DIFFICULTY CORRECTLY IDENTIFYING COLOURS?
DO YOU HAVE ANY DIFFICULTY WITH YOUR HEARING?
ARE YOU TAKING ANY MEDICATION THAT IS GIVING YOU DIZZINESS OR DROWSINESS?
HAVE YOU USED, OR ABUSED, DRUGS WITHIN THE LAST 12 MONTHS?
HAVE YOU HAD ANY ALCOHOL RELATED ILLNESS DURING THE LAST 12 MONTHS?
ARE YOU SUFFERING FROM ANY OTHER MEDICAL CONDITION WHICH MAY AFFECT YOUR ABILITY TO CARRY OUT THE JOB WHICH YOU ARE APPLYING FOR? IF YES PLEASE PROVIDE DETAILS BELOW.