MUDSA DATABASE AND SELF-EVALUATION RISK ASSESSMENT FORM

PLEASE ENTER YOUR PERSONAL DETAILS (RED SECTION) AND THOSE OF YOUR 'HELPER' (BLACK SECTION)
THEN CLICK THE 'SEND FORM' BUTTON AT THE FOOT OF THE PAGE.

RISK ASSESSMENT (SELF-EVALUATION)

PLEASE CHOOSE WHICH OF THESE 'RISK CATEGORIES' BEST DESCRIBES YOUR DISABILTY AND ENTER BELOW.

GREEN - I am Able to proceed to a safe place of refuge with the help of my assistant
GREEN / AMBER - I am able to proceed to a safe place of refuge with the help of my assistant and ONE other person
AMBER - I am able to proceed to a safe place of refuge only with the help of my assistant and TWO STEWARDS
AMBER / RED (Wheelchair users only) - I am unable to proceed to a safe place of refuge without the assistance of FOUR STEWARDS each supporting a corner of my wheelchair
RED (Wheelchair users only) - I am unable to proceed to a safe place of refuge without the assistance of FOUR STEWARDS plus auxiliary aides such as a ramp



DISABLED PERSON'S DETAILS                          TITLE
SURNAME
FORENAME
EXISTING MEMBER
DATE OF BIRTH
ADDRESS
POSTCODE
TELEPHONE NUMBER
MOBILE NUMBER
E-MAIL ADDRESS
NATURE OF DISABILITY
YOUR RISK CATEGORY (see definitions above)
MANCHESTER UNITED MEMBERSHIP NUMBER
HELPER'S DETAILS                                        TITLE
SURNAME
FORENAME
EXISTING MEMBER
DATE OF BIRTH
ADDRESS
POSTCODE
TELEPHONE NUMBER
MOBILE NUMBER
E-MAIL ADDRESS
MANCHESTER UNITED MEMBERSHIP NUMBER