In The Event of a Major Incident – Staff Questionnaire
The Trust is planning extensively for a Pandemic Flu outbreak/Major Incident which will have
exceptional demands placed on it at such time. The Trust is co-ordinating an exercise to
gather the below details and needs all new staff that join the Trust to provide the same
details. Data security is an extremely important matter and your personal details are strictly
confidential to the Trust and safeguarded as such.
Your responsibilities when you become an employee of the Trust will be that you attend work
in whatever capacity is required of you. However the Trust is also realistic and it is recognised
that children’s nurseries and schools may close for a period of time and transport may be
seriously disrupted during a Pandemic Flu outbreak/Major Incident.
Please complete and return this form with all other forms to your HR Administration. If you do
not complete and return this form it will be expected that you can work as normal throughout a
pandemic flu period.
Thank you for your cooperation.
Name: _ ___________________________________________________________________
Deaprtment:________________________________________________________________
Location Base: _____________________________________________________________
Carer Responsibilities
Are you a carer for a dependent relative who would have difficulty in coming to work if schools
and nurseries or day centres were to close?
Please tick as appropriate:
YES
NO
How would you like to tackle this problem?
Unpaid Leave
Flexible working i.e. might it be possible for you to work different hours during a pandemic flu
outbreak/Major incident?
If so, please describe below
Working from home (this might not be possible for all posts)
You may wish to consider another alternative – please describe:
……………………………………………………………………………………….....
……………………………………………………………………………………….....
……………………………………………………………………………………….....
Transport
Public transport is likely to be disrupted in a pandemic Flu outbreak/Major Incident. Would
you be prepared to give a lift to somebody else in order to enable them to get to work?
Please circle as appropriate:
YES
NO
If there was no petrol could you walk or cycle work?
YES
NO
If there was no petrol could you walk or cycle to another NHS site?
YES
NO
If yes what site ………………………………………………………………………..
If no, why not? ………………………………………………………………………..
……………………………………………………………………………………….....
Flexibility
During a Flu pandemic/Major Incident you may be asked to work at another NHS site. Would
you be prepared to do this?
YES
NO
If yes what site ………………………………………………………………………..
If no, why not? ………………………………………………………………………..
……………………………………………………………………………………….....
Accommodation
There are some members of staff who live outside the area. If there was a pandemic
Flu/Major Incident outbreak would you be prepared to offer any employees temporary
accommodation?
YES
NO
If yes, please describe ………………………………………………………………
……………………………………………………………………………………….....
Reservists
Are you member of the reserve forces?
YES
NO
If yes, please provide details……………………………………………………......
………………………………………………………………………………………….
Is your partner a member of the reserve forces?
YES
NO
If yes, please provide details…………………………………………………………
…………………………………………………………………………………………..