• Alertness and a reasonable level of fitness are essential for your duties whilst employed by the NJS Group of companies. It is important that answers you give are accurate, although trivial conditions should be discussed they may not need to be necessarily recorded. This document will be treated in strict confidence in accordance with the Company's Data protection policies. By completing this form, you are accepting a degree of responsibility for the health and safety of yourself, your colleagues and other that may be affected. Negative answers will not necessarily preclude you from employment with NJS but will enable us to assess your ability to carry out your tasks you may be required to undertake. Falsification of this document may result in disciplinary action being taken and/or the termination of your employment

  • Document No.

  • Employee Picture

  • Employee Name

  • Position

  • Date Of Birth DD/MM/YYYY .

  • Full Address

  • Contact Number

  • Conducted on

  • Prepared by

  • Location
  • Have you suffered from any of the following? Please provide details

  • Do you suffer from epilepsy or fits?

  • Please provide further details

  • Have you ever suffered from blackouts, recurrent dizziness or any other condition which may cause sudden collapse or incapacity?

  • Please provide further details

  • Do you get discomfort or pain in the chest or shortness of breath on exercise, e.g. climbing a flight of stairs?

  • Please provide further details

  • Are you currently taking any medication (prescribed or otherwise) that may affect to carry out your duties safely?

  • Please provide further details

  • Do you currently have, or previously had any injuries or illness or conditions that may affect your ability to carry out your duties safely?

  • Please provide further details

  • If required, may we contact your GP in relation to medical records?

  • Please provide further details

  • If yes to previous question, please provide your GP's name and practice address:-


    I the employee named below understand and acknowledge that should I knowingly make a false statement regarding my medical history in answering the above questions, or should I conceal wilfully any material fact. I will if engaged, be liable to have my contract terminated. In the the event of any health queries I consent to my general practitioner supplying information to company.

  • Employee Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.