Pre Employment Health Check

PRE-EMPLOYMENT HEALTH DECLARATION FORM You must complete this health declaration (and, if necessary, the Confidential Health Questionnaire). Failure to do so will mean that the appointment cannot be confirmed.

Surname:

Forename(s):

DOB:

Home Tel No:

Home Address:

Work Tel No:

Job Title:

School/Establishment:

ASHTON COMMUNITY SCIENCE COLLEGE

You should understand that it is in your interests, as well as that of your Establishment/Service, that this declaration form should be completed accurately. If it is not, you may well be employed on work that may affect your health or aggravate an existing medical condition and which may have serious consequences.

Should you encounter any difficulties in completing this health declaration you are advised to consult your General Practitioner.

Please read the attached ‘Risk Identification Form’ for the job for which you have been appointed and then answer the following questions: (Note: if you have any queries concerning the Risk Identification, please consult your Line Manager)

Do you consider you have, or have had, any physical or mental health problems that might restrict your ability to carry out the work involved with the job you are applying for?

YES

NO

Have you been absent from work due to ill health for a continuous period of four weeks or more or been absent on more than six separate occasions during the past two years?

YES

NO

Have you ever suffered any illness or injury which you consider was caused by your work?

YES

NO

Signature:

Date:

Any inaccurate or misleading answers to the above questions may lead to an offer of employment being withdrawn or disciplinary action being taken . /mnt/tmp/rs/141014111257-53c7b3c9654446c39a09dae93cbfdcd2/original.file

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What to do next…….

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If you have answered ‘Yes’ to any of the three questions above complete the attached Confidential Health Questionnaire.

If you have answered ‘No’ to all three questions check the Risk Identification Form.

Are any of the activities in Section A (1-10) marked Yes? If so, you must complete the attached Confidential Health Questionnaire. If not, you should return the Pre-employment Health Declaration form only.

Once complete this form should be returned to: HR Service Centre, PO Box 100, County Hall, Preston, Lancashire, PR1 0LD Please indicate on the envelope provided which form(s) you have completed.

FOR OFFICE USE ONLY THIS SECTION TO BE COMPLETED BY THE HUMAN RESOURCES TEAM

After consideration of the declaration made by the candidate for appointment and having given consideration to the risk assessment pertaining to the post, I consider that he/she: Is accepted as fit to undertake the full duties of the post.

Name:

Tel No:

Signature:

Date:

Masterpiece recharge code E

A A 1 5 1 0 0 0 3 2 5 0 8 0 0

14 October 2014

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Confidential Health Questionnaire This confidential health questionnaire sheet should ONLY be completed if you have answered ‘Yes’ to any of the three questions on the pre-employment health declaration form.

Surname:

Forename(s):

Establishment: Job Title:

Please complete the appropriate section(s) below: Please give details of any physical or mental health problems that might restrict your ability to carry out the work involved with the job you are applying for.

Please give details (including dates and reasons for absence) of any periods of absence from work because of ill health during the past two years.

If you have ever suffered any illness or injury, which you consider was caused by your work, please give details including approximate dates and nature of illness(s).

Please place this health questionnaire in the envelope provided and return it to the Human Resources Team. The sealed envelope containing this health questionnaire will be passed, unopened, to the County Council’s Occupational Health Service. You may then be contacted by or requested to attend the Occupational Health Unit for further assessment.

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