Title Page
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Site conducted
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Conducted on
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Conducted by
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Document Number
Personal Information
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Full Name
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Date of Birth
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Photographic I.D - E.G: Passport, Driving License
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Contact Number
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Email Address
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Home Address
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Emergency Contact Name
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Emergency Contact Details
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Bank Details
Employee
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Hire Date
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Department
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Position
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Pay Details
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National Insurance Number
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Rights to work (Gov Share code)
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P45 or P60 Given?
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Full-Time / Part-Time / Seasonal / On-Call.
Heath Questionnaire
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Have you suffered from any of the following? Please provide details
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Do you suffer from epilepsy or fits?
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Please provide further details
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Have you ever suffered from blackouts, recurrent dizziness or any other condition which may cause sudden collapse or incapacity?
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Please provide further details
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Do you get discomfort or pain in the chest or shortness of breath on exercise, e.g. climbing a flight of stairs?
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Please provide further details
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Are you currently taking any medication (prescribed or otherwise) that may affect to carry out your duties safely?
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Please provide further details
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Do you currently have, or previously had any injuries or illness or conditions that may affect your ability to carry out your duties safely?
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Please provide further details
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If required and with consent, may we contact your GP in relation to medical records?
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Please provide further details
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If yes to previous question, please provide your GP's name and practice address:-
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STATEMENT
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 employment terminated. In the event of any serious health queries I consent to my general practitioner supplying information to company.
Any other personal information?
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Please let us know...
Declaration
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Employee Signature
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Date & Time of Completion
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Manager sign off
