For the purposes of the Company’s health and safety obligations, candidates who have been offered employment with the Company must complete this form. If the answer is yes to any of the questions on this form, please give full details in the space provided of the dates, duration and outcome of the illness or condition. If we have any concerns about your fitness for work, employment will be subject to satisfactory medical reports.
Select your sex (optional)
Option to Self Describe (optional)
Enter your address (optional)
Have you ever had
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Previous Employment
Did any of your previous employments include
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
Please provide further information (optional)
I declare that the information I have provided is true to the best of my knowledge. I accept that in the event of my being employed and it subsequently being found that un-disclosed or incorrect medical information has been provided, I become liable to disciplinary proceedings which may include dismissal.
Add your signature (optional)
Draw your signature with your mouse, or your finger on a touch screen.
Please add your signature.
Thank you for completing this questionnaire.; As a result of your answers, we may require you to undergo an Occupational Health Assessment with our Occupational Health Service. They may require further information from your doctor. Please give details of
Address of the surgery (optional)
DECLARATION BY APPLICANT / Consent to release Personal Medical Information
We require this information in order to confirm the condition of your employment offer is fulfilled, that being the provisions of a satisfactory health check/to determine whether any reasonable adjustments are required in order for you to fulfil your role.
Add your signature (optional)
Draw your signature with your mouse, or your finger on a touch screen.
Please add your signature.
You have the right to withhold your consent to this action being taken. However, the inability to obtain up-to-date medical information may affect decisions made about your employment. You may ask to see the medical report before we receive it. This request for access can be made by ticking the appropriate box above (in which case, we will tell the doctor of your request and let you know when we apply for the report), or direct to the doctor at a later date, but before the report is supplied to us. If you ask to see the report. You must contact the doctor to arrange access within 21 days of us applying for the report; otherwise the doctor can give the report to us without showing it to you, without your consent. Having seen the report, you can ask the doctor to amend anything, which you think is incorrect or misleading. If the doctor does not agree, a statement of your views will be attached to the report at your request. Provided that you have seen it, the report will not be given to us unless you give the doctor your consent. You will not be entitled to see any part of the report which. The doctor believes could seriously harm your physical or mental health, or that of others. Indicates the doctor’s intentions in respect of you. Reveals information about another person, or the identity of someone who has given the doctor information about you (unless the person consents or is a health professional involved in your health care). The doctor will tell you why access to the whole or part of the report is refused. Your rights of amendment will apply only to the disclosed part of the report. Access to Work Fund. If you have a health issue and require equipment or adaptations to support you undertaking your work please read the following information. The Access to Work Fund is a government fund available to help employees overcome difficulties in the workplace resulting from a disability/ health issue. It provides funding towards, for example, special aids and equipment and adaptations to premises. The individual with the disability makes the application to the Fund by contacting their local Access to Work office who will work with the employer to provide the appropriate support. For applicants taking up a new post or in a job for less than 6 weeks the cost of the adaptation is borne wholly by the Fund as long as the application process has been started prior to this time. Although all such reasonable adaptations can be provided for you at any time during your employment your prompt application to the Access to Work Fund will ensure that any appropriate support is in place before you start. How to contact Access to Work. If you feel that the type of work you do is affected by a disability or health condition and likely to last for 12 months or more, contact your regional Access to Work centre to check whether you can get help. The regional office for the South West/Wiltshire is Cardiff (for South West England, Wales, West Midlands and East Midlands). Access to Work