Medication Declaration Form RHG-JF-229

Medication Declaration Form

RHG-JF-229 | Version 1 | Review 25/01/2027
Date

DayMonthYear
Date
Submitters Name*

First NameLast Name
Submitters Email*
example@example.com
Phone Number*
Business Unit*
Manager/Supervisor*

First NameLast Name
Manager/Supervisor's Email*
example@example.com
You DO NOT have to inform your Manager/Supervisor if you are taking the following:
- Paracetamol (Panadol)
- Ibuprofen (Nurofen)
- Contraceptive pill
- Thrush Medication
- Aspirin
- Hormone Replacement Therapy
- Anti-viral medication
- Sexual performance-enhancing medication
I am declaring the medication below*
Photographic Evidence of Medication*

(prescription note or letter from GP or sticker on medication box)
Cancelof
DECLARATION
- I hereby declare that the prescribed medication is intended solely for my personal use.
- If needed or upon request, you can provide a copy of the prescription.
- I acknowledge that I need to inform my Manager/Supervisor if I am taking any prescription or non-prescription medication which may affect my fitness for work and/or impact a drug testing result.
- I understand that Railtrain Holdings Group (RHG) may require documentation from my treating medical practitioner to confirm I can safely perform my role whilst utilising this medication.
- I have been informed and understand the potential side effects associated with the use of this medication.
- I am aware it is my responsibility to manage my fitness for work.
Signature

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