Name *

First Name

Last Name

Are you able to move and handle a range of equipment? *

Yes

No

Are you able to move, play with and handle children? *

Yes

No

Are you able to frequently lift/bend/push/stop/stoop? *

Yes

No

Do you have/have you had any major illnesses/absences? *

Major illnesses include heart, blood pressure, respiratory problems (asthma), diabetes, epilepsy, any back conditions or mental illness and any conditions requiring referral to a medical or surgical consultant

Yes

No

Have you ever been retired or had your contract terminated due to ill health? *

Yes

No

Do you have any medical condition which may affect your work?

Yes

No

Are you under any medical treatment/supervision at present? *

Yes

No

Do you have any significant infectious diseases such as tuberculosis or hepatitis, which may pose risk if not treated?

Yes

No

Do you have a mental health condition?

Yes

No

Do you have any alcohol / drug dependancy or misuse?

Yes

No

Do you smoke or vape?

Yes

No

Are you fully vaccinated against Covid-19?

Yes

No

Do you consider yourself to be a disabled person? *

Yes

No

Do you need any reasonable adjustments to support in your job role? *

Yes

No

I declare that to the best of my knowledge the information on this health declaration form is true. I understand that if the information I have supplied is false or misleading in any way, I may be automatically be disqualified from my appointment or dismissed without notice. *

Yes I declare the information provided to be true

If there are any areas of this form that require further medical information I am willing to sign an additional form giving you consent to contact my doctor for a medical report. *

Yes I consent for you to contact my doctor

No I don't give my consent for you to contact my doctor

Date of completing this form *

MM

DD

YYYY