Health Declaration

Step 1 of 3 - Personal information

Signature

Date(Required)

DD slash MM slash YYYY

Due to the nature of the role you have applied for we need to carry out a complete a new starter health questionnaire – even if you have been employed in UK health services before. The health of each candidate is considered individually and a decision regarding fitness for work in the prospective job role will be based on the functional effects of any underlying health condition/disability/impairment as well as health service requirements for fitness and immune status.

Before health clearance is given for employment you may be contacted by Healthier Business UK Ltd and may need to be seen by an occupational health advisor or physician with gained consent. We may recommend adjustments or assistance following an assessment to enable you to carry out your proposed duties safely and effectively. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice. Our aim is to promote and maintain the health of all individuals in the workplace: staff, service users and third parties. Your records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations. Your records will be held on file for the purposes of processing your request only and for no longer than is necessary, however your records may be subject to internal clinical audits. Your records may also be used to cross reference and ascertain your fitness should you register with other clients of Healthier Business UK Ltd.

Personal information

Title(Required)

Name(Required)

First Last

Email(Required)

Date of birth(Required)

Day

Month

Year

Home phone(Required)

Work phone(Required)

Mobile phone(Required)

Home address(Required)

GP address(Required)

Job role or prospective job role(Required)

Medical history

Do you have any illness/impairment/disability (physical or psychological) which may affect your work? i.e. ADHD, depression, anxiety.(Required)

Yes

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?(Required)

Yes

Do you take any prescribed medication?(Required)

Yes

Are you having, or waiting for treatment (including medication) or investigations at present?(Required)

Yes

Have you had any surgery in the last 12 months?(Required)

Yes

Have you had any hospital admissions in the past 12 months(Required)

Yes

Do you think you may need any adjustments or assistance to help you to do the job? I.e. Dyslexia, Irlen Syndrome.(Required)

Yes

If you have answered yes to one or more of the medical history questions, you must provide further details in this additional information section. Failure to do so will result in the form being returned/rejected.(Required)

If you have answered 'yes' to any questions above, please provide additional information including dates, treatment and details of condition)

Have you lived outside the UK or had an extended holiday outside the UK in the last year?(Required)

Yes

Have you received a BCG vaccination in relation to tuberculosis?(Required)

Yes

Have you got a cough which has lasted for more than 3 weeks?(Required)

Yes

Unexplained weight loss?(Required)

Yes

Unexplained fever?(Required)

Yes

Have you had tuberculosis (TB) or been in recent contact with open TB?(Required)

Yes

Consent

Consent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed. You have the right to withdraw your consent at any stage of the process, either verbally or in writing.

Further information regarding consent is available on the ‘Candidate Screening Leaflet’.

Do you consent to this questionnaire, and supporting documentation being assessed by an occupational health advisor for the purpose of providing a fitness to work certificate?(Required)

Yes

Do you consent to our occupational health advisors speaking with you regarding any declaration that you have made relating to your medical history?(Required)

Yes

I will inform my employer if i am planning to or leave the UK for longer than a three-month period(Required)

Yes

To enable a reassessment of my health to be conducted on my return.(Required)

Yes

All information supplied by you will be held in confidence by Healthier Business UK Ltd. Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. Your data may also be cross referenced should you have registered with other clients of Healthier Business UK Ltd. Your personal data may be required to be seen by an occupational health advisor or physician; however it will not be shown, nor their contents shared with anyone - including Managers, Human Resources Advisors, GP’s, Specialists or third party’s - without your explicit consent. You have the right of erasure (the right to be forgotten), refusal of consent and withdrawal of consent without detriment (withdrawal of consent can be exercised at any stage of the process). The only exceptions to this may be a court order for release of records in a judicial dispute or where there is a public responsibility obligation.

Further information regarding your rights under GDPR can be found on the following: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/

If you wish to have sight of our privacy policy, please send your request to support@hbcompliance.co.uk

Declaration

I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.(Required)

Yes

Signature(Required)

Name

This field is for validation purposes and should be left unchanged.

Health Declaration