New Starter Health Declaration

New Starter Health Declaration
Instructions

The purpose of this declaration to establish your medical fitness for the job and whether any adjustments or support is required. In most instances this can be decided from the information given in the questionnaire. If however further details are required, you may be asked to attend for a health interview with an Occupational Health Advisor, or a medical examination with a Doctor. We may require further information from your General Practitioner. If this is the case, we will write to you.

It is in your interest, as well as that of your prospective employer, that all the questions are answered accurately. This will enable your prospective employer to be advised as soon as possible of your fitness status.

All medical information will be treated as CONFIDENTIAL. Should you require assistance in completing this form, please do not hesitate to contact Work-Life Health Ltd.
Name*

TITLEFIRSTNAME (Name known by)SURNAME
DATE OF BIRTH*

DayMonthYear
NI NUMBER:
Address

Street

Street Line 2

Town / CityCounty

Post Code
TELEPHONE:
Please enter a valid phone number.
MOBILE:
Please enter a valid Mobile number
EMAIL*
example@example.com

GP NAME:
GP TELEPHONE:
Please enter a valid phone number.
GP ADDRESS (inc postcode):

Street

Street Line 2

Town / CityCounty

Post Code

COMPANY NAME:
Enter your Company Name
POSITION:
HOURS PER WEEK:
PATTERN OF WORK:
Privacy Notice – How we use your information

Work-Life Health Limited is registered with the Information Commissioners Office (ICO) under the provisions of the Data Protection Act 1998 and takes its responsibilities under the Act very seriously.

The information provided by you is collected purely for the purposes of ensuring that you are ‘fit for work’ and to ensure you have the appropriate support in the workplace if you have a particular health need. We collect this information in order to determine your fitness for role you have applied for and also to support you in the workplace. Completion of this form/sharing your information with us constitutes explicit consent from you for us to process your data for this purpose.

Processing is necessary for the purposes of preventative or occupational medicine, for assessing your working capacity, medical diagnosis, the provision of health or social care or management/treatment of health or social care systems. You have the right to see what information is held about you, to have inaccurate factual information corrected and to have information removed from your system (unless we are required by law or a statutory purpose to keep it) by contacting the Director, Ruth Milner, Work-Life Health Limited, PO Box 739, Halifax, HX1 9AY. You have the right to complain if you feel that your data has not been handled in accordance with the law to ruth.milner@work-lifehealth.co.uk.
Information about your fitness for work will be passed to your relevant HR representative and held on our system. Anonymous Occupational Health data will also be used for statistical purposes in order to monitor Occupational Health provision for your employers. The data will form part of an Occupational Health record and kept until the age of 75 years or for 6 years from the date of leaving this employment. Data of unsuccessful candidates will be held on file for 6 months and then destroyed. Retention periods are reviewed regularly and in the light of new legislation.

NOYES
If you answered YES - Please give details

NOYES
If you answered YES - Please give details

NOYES
If you answered YES - Please give details

NOYES
If you answered YES - Please give details

Occupational Drivers and Company Car Drivers Only

If you will/may need to drive for work purposes, please answer the following:
NOYES
Managerial and Administrative/Office Staff Only
NOYES
I certify that the information given by me for the purpose of this enquiry is true; to the best of my knowledge and belief, and that I have not withheld any material facts. I understand that, in the event of my knowingly making a false statement or concealing pertinent information, Work-Life Health may disclose to my employer that a false statement has been made, without releasing medical details of that false statement without my further consent. I understand that my employer may treat this false statement as gross misconduct and terminate my contract.
Signature*
Date

DayMonthYear
Date
Name

First NameLast Name
PLEASE CHECK:
- That you have completed all the sections in the declaration form. Failure to complete all sections may result in the form being returned to you and a delay in your appointment.
- That you have not referred us to a document held by your employer, as Work-Life Health does not have direct access to any documents held your employer and this might delay your appointment.
- That you have not included any other information required by your employer with this document as your employer does not have sight of the form.
Should be Empty:

Rows	No	Yes	Details including dates
Respiratory problems/lung disorder (asthma, tuberculosis, bronchitis etc.)
Skin problems(eczema, dermatitis etc.)
Psychological problems(anxiety, depression, stress etc.)
Back or neck problems(deformity, aches, pains, arthritis or injuries etc.)
Impairment or disability of the upper or lower limbs e.g.: -- Tenosynovitis - Tendinitis- Epicondylitis - Carpal Tunnel Syndrome - De Quervains’ Syndrome - Trigger Finger - Tennis Elbow- Golfers Elbow- Repetitive Strain Injury (RSI) - Work Related Upper Limb Disorder (WRULD) - Cervical Spondylosis - Frozen ShoulderInjury to the upper or lower limbs or fractures
Visual problems (eye infections, tunnel vision, blindness)
Hearing problems (ear infections, deafness)
Neurological problems (epilepsy, fits, dizzy spells, or blackouts)
Diabetes
Sensitivities and allergies (food, medicines, latex, dust)
Migraine or headaches
Communication (speech) problems
Heart or circulatory problems (high blood pressure, angina etc)

New Starter Health Declaration

PLEASE CHECK: