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Occupational Health, Safety & Welfare

fitness & health for all employees

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Self Rating Questionnaire

Incident:   

Date:

Following the above incident, have any of these symptoms caused you distress at least twice in the last week? If so, place a yes/no in the appropriate box.  

This form will allow you to consider the question on several occasions.

Question Date Date Date Date
         
Against your will you have upsetting thoughts or memories about the event        
Acting or feeling as though the event were happening again        
Feeling upset by reminders of the event        
Bodily reactions when reminded of the event (sweating, dizziness, sickness, rapid heart rate)        
Upsetting dreams about the event        
Difficulty falling or staying asleep        
Irritability or outbursts of anger        
Difficulty concentrating        
Heightened awareness of potential dangers to yourself and others        
Being jumpy or startled at something unexpected        

If you experience one or more of these reactions at least twice in the last week you may find it useful to talk to your Officer in Charge, manager or someone who is close to you, about your reactions.  Alternatively you can contact the Occupational Health or Welfare Adviser or the Divisional Chaplains.

If you experience six or more symptoms, it is very important for you to contact the Occupational Health or Welfare Adviser for support.

The HFRS Chaplain:

           The Occupational Health, Safety and Welfare Unit, Steele Close, Eastleigh

Welfare Adviser:

Occupational Health Adviser: