Health and Safety Questionnaire Completion of this questionnaire assists us to comply with statutory health and safety requirements (as outlined on page 3 of Guidelines for Placement Providers / Supervisors (Form MP2). The placement supervisor is asked to complete it or arrange its completion eg by the placement agency’s administrator.
Trainee’s Name ..………………………………………………… Personal Tutor’s Name ……….…………………………….……….
Placement Name ……………………………………………………………………………………………………………………………… The questionnaire below was completed by: (Name) …………………………………………………………………………... (Role) ……………………………………………………………………….……. (Signature) ……………………………………………… Date ….……………
Personal Tutor's signature........................................................….………………………..... Date ……………………..
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