Statement of Physical Fitness
This statement contains the physical demands that may be experienced during our courses. This form must becompleted by a qualified physician concerning your health and then submitted along with the ‘NSTC Training
Medical Screening and Self-Declaration of Fitness Form’; both required before training.

Contents of Training
Helicopter

Delegates are inverted and rotated in a simulator (min. of 3 times) while wearing a seatbelt

Underwaterthen required to escape, unassisted, from said simulator whist underwater (in a 5 meter inEscapedeep heated indoor pool) etc.. Delegates may also employ a survival suit and use are-breather escape set.

Sea Survival

Delegates participate in Sea Survival Training with life vests in a heated indoor pool;consisting of: water entry from 1m, swimming/ towing other delegates, treading water,climbing in/out of a life raft from the water etc. Being winched from water employing ahelicopter rescue strop under the arms and secured around the upper torso.

First AidDelegates participate in First Aid Training including CPR (Cardio Pulmonary Resuscitation)
on a training mannequin.

Lifeboat

Delegates participate in the embarkation of a lifeboat quay-side at our Lifeboat Facility.
After launch, they must climb back to the quay.

Firefighting

Delegates are required to use a fire blanket and a range of fire extinguishers to extinguishsmall to medium fires at close proximity. Delegates will have to carry portable extinguishers(up to 21kg) to extinguish the fires.

Evacuation /Delegates are required to navigate through a smoke-filled location or zero visibility for up toSelf-Rescue

10 minutes in length while donning an escape breathing device.

Delegate’s Information
Name

Date of Birth

Y:

M:

D:

Medical Concern (Below to be completed by physician .)Blood PressureSyscmkg

DiaPulse

HeightWeight

Respiratory

NormalProblematic

Cardiovascular

NormalProblematic

Motor Function

NormalProblematic

Otological

NormalProblematic

Neurological

NormalProblematic

Other Complications

NormalProblematic

Please give details if any “Problematic” conditions from the above are found.

(Use back of page if further explanation is required)I verify that thisPhysician ’s name:individual is fit toDate of examination:Y:undertake training
Organizations’ Name:

Yes／ NoTelephone:

Address:*This document is valid for one year after completed by a qualified physician.

M:

D:Physician’s Additional comments(This space provided for further details, concerns and/or special criteria needed)

NSTC Training Medical Screening and Self-Declaration of Fitness Form
NSTC 訓練参加のための健康状態申告書
1.

Please read the following carefully:

Physical activities associated with this training course may include, but are not limited to:

2.

Moving through the water using your arms while wearing a life jacket and/transit or immersion suit.
Holding your breath to egress underwater in a helicopter simulator module.
Entering the water from pool side or at height 3.3ft or 1m.
Towing other persons in the water.
Pulling action on the upper body when climbing in or out of the pool or up and into a life raftfrom the water. (Similar to doing a chin-up but with an additional 20 lbs/10kg of weight
added to your body.) Extensive use of joints – shoulders, neck, elbows, wrists, hips,knees.
Twisting and torqueing the upper body.
Breathing from emergency breathing devices.
Sitting in a classroom environment for at least 50 or more consecutive minutes.
Crawling over/under objects in low visibility situations

Delegate Medical Self Declaration

The following questionnaire is provided for your personal review. If you have any of the following
medical conditions or answer yes to any of the questions you are advised to: Provide the list of training requirements to your physician
 Consult with your Physician to determine if you are fit to safely complete the training

This medical questionnaire may be voluntarily used to discuss whether you are physically able toparticipate in NSTC course(s). This list of questions is by no means an exhaustive list of all questions you
should discuss with your medical provider. Instead, it is being provided to you as guidance of whatquestions you may want to discuss with your medical provider prior to signing your Training Participant
Medical Declaration acknowledging your fitness to participate in the training program.

QuestionsHave you been under surgical intervention recently?
Do you have any physical disability?
Do you wear prescription glasses or contacts?
Are you presently on light duty because of a medical condition?
Did you have any disease, altered state of health or any lost time
accident in past 12 months?
Have you been treated or being in the care of a doctor in the last 12
months for any medical condition that would require a doctor’s release?
Are you suffering from any physical or physiological condition notmentioned that could affect your participation in any of the physicaltraining activities?
Do you have any anxiety that could prevent you from safely completing thistraining? (Height, Enclosed Spaces, Water, etc.)
Have you ever had epilepsy/ seizures / fainting / “blackout”?
Have you ever had a head injury?
Do you have any problems with headaches / balance / hearing?

Yes NoIf Yes, What and When?

NSTC Training Medical Screening and Self-Declaration of Fitness Form
NSTC 訓練参加のための健康状態申告書
Do you have trouble with swimming?
Are you a limited or non-swimmer?
Are your ears sensitive to water? Have you had previous ear issues
while swimming or after swimming?
Do you have shortness of breath/breathing difficulties?
Have you suffered chest pains?
Do you have a history of displaced joints (bad knee, bad back etc.)?
Are you allergic to any medicine/substance?
Are you pregnant? If Yes, How long have you been pregnant?
Have you taken any medication in the past 24 hours that could impair yourability during this training?

Do you suffer or have you suffered from?
RESPIRATORY Diseases (allergies, asthma, bronchitis, tuberculosis orother)
CARDIOVASCULAR diseases (heart attack, angina, thrombosis, phlebitis orother)
DIGESTIVE SYSTEM Diseases (gastritis, ulcers, hepatitis B/C or otherdiseases)
URINARY SYSTEM Diseases (infection, kidney stones or other)
METABOLIC Diseases (diabetes, obesity, anemia or other)
BONE SYSTEM Diseases (arthritis, bone fracture, dislocation, slipped
disc, rheumatism or other)
NEUROLOGICAL Diseases (epilepsy, depression or other)
SKIN diseases (ringworm, folliculitis, herpes or other)
EYES Diseases (myopia or other)High blood pressure
VARICOSE veins (poor circulation, and phlebitis)
Hernias, Hemorrhoids or Fistulas
Please list any other medical problems or recent injuries that may
limit your ability to safely complete this training.

NameI understand that all the above information that I have supplied will be kept “most confidential” unlessissues arise regarding my health and safety. Should an incident occur, I agree that any informationneeded to aid in my care can be released.
I have read the above and declare that all information provided on this form is accurate and that I
have not withheld any information regarding the status of my health.
I am aware that the occurrence of any accident or illness in training must be immediately reported tothe instructor or the responsible health professional.

Signature

Date

DAY / MONTH / YEAR

Training Consent Form
1. I understand that I will be involved in the following activities that take place during training:(1) Egressing from a simulated helicopter; ①Inverted ②Surface ③Submersed, in water.
(2) Use of a PFD(Personal Floatation Device) during Sea Survival Training (Water entry [1m inheight], swimming, towing, use of a life raft, being hoisted from water by rescue strop).
(3) Basic First Aid employing a training dummy.
(4) Use of a Davit Lifeboat System.
(5) Extinguishment of a fire and fire extinguisher implementations.
(6) Evacuation training from obscured and/or zero visibility (blindfold/cosmetic smoke).
2. I understand there are risks associated with this training and I take full responsibility for any injuries
and/or losses that may occur to me or others due to my negligence during training.
3. I enter into this training with a positive attitude and responsibility towards the health and safety ofothers.
4. I understand that I will not obtain my certificate if I do not participate in all sections of this training(Lecture and Practical).
5. I give the staff full permission without repercussion from me or anyone associated to me toadminister First Aid and will follow all directions given in the event of an emergency.

Expected date of training: YM

D～YDate：YM

M

DDSignature:※ You may elect to not participate in any part of this training even though all aspects of this training
must be completed to fulfill the required assessment. This includes but not limited to the lecture,
Test and practical application sections.

NSTC
Document Code:QMS10610
Reference
Personal Information Consent Form

Issue #:
001
Issue Date:
03/14

Revision #:Revision Date:

個人情報の取扱いに関する同意書

Prepared by:TN
Approved by:
RIPage1 of 2Your Privacy Matters to Us
At NSTC (Nippon Survival Training Center), we are committed to protecting your privacy. We respect your privacy andwant you to understand how we safeguard your personal information.
How We Collect Your Information
We collect and keep information about you, which is needed to provide the products and services you request. We
collect information from you, either directly or through your company’s representatives.
How We Use Your InformationWe use your personal information to provide the products and service you or your company requests, which includes:
 Creating training certificates Maintaining a record in our training database Creating invoices and receipts
We may be required to share or distribute your personal information to third party organizations that require yourinformation in order for NSTC to issue certification.
The Certification Body of specific training Insurance company
 Your employer
 Relevant company requiring your training history
We may use your information internally to create statistical reports that help us understand the needs of our clients andhelp us manage our business.
Security
NSTC will not release your personal information to any person or organization that is not reasonably involved in thedelivery of your requested service or product.
 Paper files containing your personal information are secured (locked storage) as soon as processing iscompleted. These files are kept for a period of five years and then destroyed.
 Electronic files are backed up daily. If not updated, your personal information will automatically be deleted
after five years.
Your Right to Access Your Information
You have a right to access the personal information that we have about you in your file. If we have information that is notcorrect, you can have it corrected. To access your information or to ask us to correct information, you can contact us at:
 2-6-27Ginza, Tobata-ku, Kitakyushu-shi, Fukuoka-ken, 804-0076, Japan TEL : +81-93-884-2020
 info@n-s-t-c.com
or in person / writing
Consent
Do you understand and consent to Nippon Survival Training Center gathering your personal information for the purposes
described above? If yes, please sign below.
Print Name:

Date:Signature:（本文を）印刷した場合、管理の対象外とする。
If printed, this is an uncontrolled copy.