APPLICATION FOR INCLUSION ON IHE REGISTER OF ROAD SAFETY AUDITORS

Please complete all sections in full avoiding attachments

1. Surname / Family Name:

Forenames: Title: (Mr/Mrs/Ms/Miss):

Home address:

Postcode:

Email:Tel:

2. Employer:

Address:

Postcode:

Your Office Tel:Fax:

Office Email:Please use: my Home email Office email Both

3. Brief description of current role and responsibilities and length of time in that role:If applicable, please include any details of financial and resource management/responsibilities and any detail relating to roles involving Road Safety policy, procedures or strategies

Role Description / Length of time in role

4. Professional Institutions: List any memberships with dates of election.Please also provide details of any position you may hold within a Professional Institute, such as Branch Committee Member, or National Council Member

Institute / Date of Election / Grade

5. Educational Qualifications –(post school)

Qualifications Achieved / Dates / Where studied and where awarded / Certified by (awarding body)

6. Employment History

Please list brief details of employment history.

Employer / Dates / Job Title, description of your work

7. Continuing Professional Development (CPD)

Please provide details of CPD undertaken in the last 12 months in the fields of Road Safety Audit, Collision Investigation and Road Safety Engineering. State whether formal training, or structured reading/ forum attendance

CPD undertaken (including type of CPD) / Type of CPD / Dates / Provider

8. Road Safety Training

Please listALLrelevant formal training in Collision Investigation, Road Safety Audit and Road Safety Engineering (minimum 10 days relevant formal training)

Course / Dates / Organiser/Location

*Certificate of Competency in Road Safety Audit – Please state whether you have been awarded a Certificate of Competency in Road Safety Audit (in accordance with IAN 152/11)

Awarding Training Provider/Body / Date

9. Road Safety Experience

Please describe in a 1000 words your Collision Investigation and Road Safety Engineering experience in reverse chronological order detailing a minimum of 5No schemes undertaken in the last 2 years and your involvement and responsibilities in each of those schemes.

10. Road Safety Audit Experience

Please describe ALLthe Road Safety Audits you have been involved in, over the most recent 2 years.

Scheme description / Date / Role:
(Leader
Member/ Observer) / RSA Stage / Responsibility:
Author (A) or Checker (C)

Evidence: From the Road Safety Audit list above,please provide 5 previous Road Safety Audit reports (preferably at varying Stages) which you have been involved, each with a minimum of 4 no. problems identified(In PDF format).

Note: The submitted Road Safety Audit Reports will be treated in confidence and only forwarded to the IHE reviewers related to this application. You may be required to seek client approval before providing copies of Road Safety Audit Reports to the IHE.

11. For which level of registration are you applying?Please refer to IHE Register of Road Safety Auditors for level definition

FoundationPractitionerLead Practitioner*

*Applicants for Lead Practitioner must additionally submit a 1000 word report demonstrating their relevant leadership, training and policy experience in the fields of road safety engineering and Road Safety Audit

12. Statement by Applicant

I declare the information in this application to be complete and correct.

Signed…………………………………………Date…………………………………………….

13. Statement by Witness

Applications must be supported by an appropriate person vouching for the candidate’s submission. The witness should hold a recognised qualification in the field of Road Safety, civil engineering or Transport Planning or hold a senior position within a relevant company or organisation.

I certify that all information given in this application is, to the best of my knowledge, complete and correct.

Name…………………………………………..Professional Grade/Institute ………… …………. Position……………………………………………..

Signed………………………………………….

IHE Membership Manager is the data controller for the personal data in this form for the purposes of the Data Protection Act 1998.

You have a right to a copy of the data held on you and to ask for any inaccuracies to be corrected.

INSTITUTE OF HIGHWAY ENGINEERS, De Morgan House, 58 Russell Square, London WC1B 4HS

Tel: 020 74367487Fax: 020 7436 7488Email:

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IHE-RSA-REG/APPLICATION/01 V2