Title Page
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Full Name
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Date of Birth
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Address
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Phone Number
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Email address
Bank Details:
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National Insurance Number
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Bank Name
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Account Name
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Account Number
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Sort Code
Documents required:
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Copy of ID or Passport
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Copy of Driving Licence
Emergency Contact:
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Full Name
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Address
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Phone Number
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Email
Job Details:
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Job title
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Start Date
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Hours per week
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Hourly Rate
Health Questionare
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Next Level Commercial Services is committed to the health and safety of its staff. As part of this commitment, this questionnaire is required to be completed by all staff prior to taking up employment with our support.
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Next Level Commercial Services, like every employer is bound by The Management of Health and Safety at Work Regulations 1992, which are supplemented by an Approved Code of Practice. We are required to make assessments of risks to which employees may be exposed at work, and a proper risk assessment involves considering not only the nature of the job, but also the fitness of the employee to carry out that work. In addition the Disability Discrimination Act 1995 imposes a further obligation on the prospective employer to make, where appropriate, reasonable adjustments to enable a suitably qualified candidate to take up propose employment.
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This Pre-employment questionnaire, supplemented where necessary by a further medical assessment, is part of the Next Level Commercial Services fulfilment of our legal responsibilities in respect of the above two pieces of legislation.
Medical History :
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Please complete the following questions by choosing YES or NO answer.
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Have you ever suffered from any of the following illness:
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Visual impairment/eye conditions (including colour-blindness)
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Hearing impairment/ear conditions
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Severe anxiety, depression, other psychiatric disorder
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Paralysis or other neurological disorder
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Fainting attacks, blackouts, epilepsy or fits
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Recurrent headaches, migraine
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Heart disease, high blood pressure
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Asthma, bronchitis, tuberculosis or other chest disease
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Peptic ulcer or other digestive or bowel disorder
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Recurrent backache, arthritis, rheumatism
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Eczema, dermatitis, other skin conditions
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Any alcohol or drug related problem or illness
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Are you at present on any medication or treatment prescribed by a doctor?
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Your employer has a duty under the Disability Discrimination Act 2005 (DDA) to support individuals with disabilities that may affect them at work Do you feel that you have any condition that may be included under the DDA and which may affect your ability to do this job e.g. mobility, physical strength or stamina, sight, hearing, speech, mental illness / impairment etc?
Declaration
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I declare that, to the best of my knowledge, the information I have given is correct. I understand that I may be required to attend a medical examination. I understand that failure to disclose relevant information or giving false information may result in termination of my employment
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Signature
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Date
