Pre-Employment Health Declaration

Pre-Employment Health Declaration
Employment with McCarter Group (“Company”) is conditional on the applicant being suitable for employment and fully able to perform the inherent requirements for the position. Your answers to this questionnaire will be CONFIDENTIAL to the Company and will not be given to anyone else without your written permission. The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace.

You are required to disclose to the Company any pre-existing illness, disease, injury, aliment or condition that you have suffered or continue to suffer of which you are aware and could reasonably be expected to foresee, and could be affected by the nature of the proposed employment.

Should any circumstances change that may affect your capacity to perform the inherent requirements of the position that you are undertaking, you are obliged to inform your respective manager or the management.

Your details
Name*

First NameLast Name
Job title*
Email*
Work email
Mobile phone number*
Department / Company*

AuditAccountingTaxSecretariatAdmin

Section 1 – General Health Status
1. Are you aware of any circumstances regarding your health or capacity to work that would interfere with your ability to perform the duties of the position? In answering this question Yes or No you are also covering factors such as: existing or exposure to infectious diseases, taking of medication/treatment on a regular basis (daily, weekly, monthly).*

YesNo
If Yes, please provide details
2. Do you have an existing injury or condition or pre-existing injury or condition? Existing is a condition for which treatment is still being received. Pre-existing is where an injury or condition/s is present but treatment is not required. If yes please provide details of the injury or condition(s).*

YesNo
If Yes, please provide details
3. Have you ever been medically retired from a previous position?*

YesNo
If Yes, please provide details

Section 2(i) – Health Questionnaire

Current Medical Treatment
1. Are you attending a GP for treatment, attending a hospital for treatment or currently awaiting an appointment for treatment?*

YesNo
Further details
2. Are you receiving any prescribed medications (tablets, inhalers, creams, injections, etc.) at the moment?*

YesNo
Further details

Section 2(ii) – Health Questionnaire

Past Medical History
1. Do you have, or have you ever had, any health condition which may have been caused, or made worse, by work?*

YesNo
Further details
2. Do you consider yourself to have a disability? If yes please specify the disability.*

YesNo
Further details
3. Have you ever been declined ill health benefits or told you would not be eligible for them?*

YesNo
Further details
4. Have you ever had any difficulties at work or in education as a result of a medical condition or learning difficulty (including autism, dyslexia, dyspraxia and Attention Deficit Hyperactivity Disorder – ADHD)*

YesNo
Further details

CONFIRMATION & DECLARATION
I HEREBY DECLARE that I have read and understood all the information, declarations, and restrictions provided in this Declaration. I have answered the questions above truthfully and honestly, to the best of my knowledge and belief.

Should any of the circumstances above change, I shall inform the Management immediately.
Signature*
Date*

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Date
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