(Note to employer: this form must not be used as part of the recruitment process)
(Private & Confidential)
This form should be completed by the employee and returned to your employer.
This information is collected in the company’s legitimate interest to ensure that we meet our duty of care for our employees. The information provided on this form will be used by the organisation to determine if it is safe for you to undertake a work task or if the activities that you are required to undertake will exacerbate any pre-existing medical conditions. The form will be handled in strict confidence and all information stored according to the requirements of the applicable data protection legislation – for more information please see our privacy notice.
Based on the information provided, we may need to seek advice from a doctor, or occupational health specialist. It may also be necessary for you to regularly attend health surveillance during your employment if determined by the company risk assessments or medical practitioner. Advice regarding fitness for work will be accessible to management in general terms, however, detailed clinical information will not be revealed without your consent.
If further information is required from your doctor or health specialist, this will only be obtained with your written consent.
This job involves/may expose employees to:
-
Regular Display Equipment (DSE) Usage
-
Food handling
-
Latex materials
-
Regular manual handling/lifting duties
-
Human blood, tissues, fluids or biological agents
-
Noisy environments
Health history
​
Do you have, or have you previously had, any of the following health conditions?
​
-
Giddiness, fainting attacks, epilepsy
-
Mental illness, anxiety or depression
-
Recurring headaches
-
Serious injury or operations
-
Serious hay fever, asthma or recurring chest infections
-
Recurring stomach or bowel trouble
-
Recurring bladder trouble
-
Stroke, heart trouble, high blood pressure or varicose veins
-
Diabetes
-
Skin trouble
-
Ear trouble or deafness
-
Colour vision or eye trouble not corrected by glasses or contact lenses
-
Back or muscle/joint trouble
-
Hernia or rupture
If you answer “yes” to the above questions, you may be asked to see a doctor or nurse for further assessment.
Disabilities
Do you have any disabilities the affect the following?
​
-
Walking
-
Climbing stairs
-
Lifting
-
Using your hands
-
Driving a vehicle
-
Working at heights
-
Climbing ladders
-
Working on staging
Declaration:
I confirm that to the best of my knowledge and belief, the above information is correct. I understand that any failure to disclose information could lead to a re-assessment of my general fitness, which could ultimately lead to the termination of my employment.
