Title Page
-
Employee Name
-
Department
-
Date Form Completed
-
Date of Birth
-
National Insurance Number
-
Bank Account Details
-
Account Number
-
Sort Code
-
Name on Bank Account
-
Proof of Right to Work
-
Documentation Shown
-
Original Seen and Photograph is a True Likeness
-
Documentation seen by
-
Next of Kin Details
-
Next of Kin Name
-
Next of Kin No
-
Relationship to Next of Kin
Medical Questionairre
-
Have you ever had to give up a previous job for medical reasons?
-
Please give details
-
Have you been off work continuously for more than a month in the last five years?
-
Please give details
-
Do you regularly take tablets or medicine?
-
Please tell us what and if it has any side effects that may impact your job
-
Do you wear Glasses or have any Eye Sight Problems?
-
Please give details
-
Do you have any Hearing issues?
-
Please give details
-
Do you have any Physical or Mental Impairment that could be classed as a Disability under the Equality Act 2010?
-
Please give details
-
Are there any reasons why you should not do shift work?
-
Please explain
-
Are you able to carry out physical work such as lifting, climbing ladders etc?
-
Please explain
-
Has any previous occupation caused you any Health Problems?
-
Please give details
-
Do you suffer from any of the following:
-
1 Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness?
-
2 Vertigo, dizziness, giddiness, problems with balance?
-
3 Recurrent headache or migraine?
-
4 Diseases of the nervous system e.g. neuritis, stroke, multiple sclerosis?
-
5 Angina, heart disease or breathlessness?
-
7 Raised or low blood pressure?
-
9 Asthma, bronchitis, emphysema, pneumonia or any other lung disease?
-
10 Jaundice or any form of hepatitis or other liver problem?
-
14 Psoriasis, eczema, allergic skin rash or other skin disorder?
-
16 Anxiety/depression, mental breakdown or stress related problems?
-
20 Any operations or surgical procedures?
-
21 Ear trouble or infected ear?
-
24 Anxiety, depression or any other mental health condition?
-
25 Peptic, gastric or duodenal ulcer?
-
26 Any other serious illness not covered above?
-
Please sign to confirm that all of the information in this form is accurate
-
Name
