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If you want to apply offline, please click here to download the form

Name:

Select

Forename

Surname

Middle Name

Position:

DOB:

dd-MMM-yyyy

Address:

Phone Number:

Mobile:

GP Name:

Phone:

GP Address:

Medical History:

Yes/No

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?

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

Are you having, or waiting for treatment (including medication) or investigations at present? If your answer is yes, please provide us further details of the condition, treatment and dates

Do you think you may need any adjustments or assistance to help you to do the job?

If you have indicated yes to any of the above questions you must provide further details in additional information section, failure to do so will result in the form being returned or rejected.

Additional Information:

Medical History:

Yes/No

Have you had a BCG vaccination in relation to Tuberculosis?

Have you had Triple vaccination as a child (Diphtheria Tetanus / Whooping cough)?

Have you had Polio vaccination

Have you had Tetanus vaccination?

Hepatitis B

Have you ever had chicken pox or shingles?

Medical History:

Yes/No

Diabetes

Heart or circulatory disorders

Stomach or intestinal disorders

Any condition which causes difficulties with sleeping

Chronic chest disorders (especially if night time symptoms are troublesome)

Any medical condition requiring medication to a strict timetable

Any other health factor that might affect fitness at work

Are there any medical reasons or are you currently taking any medication, which may affect your ability to work night

If you answered YES to any above, please provide full details here

I declare that, I have understood all questions and have answered them correctly to best of my knowledge.

Name

Date

dd-MMM-yyyy

Recruiters assessment

After reviewing the questionnaire, my assessment is that you can

Can work nightCannot work night

Recruiters assessment

Should see a doctor or health professional to assess whether you can work night

Recruiter name:

Date

dd-MMM-yyyy