Clone of N3 Display UKKA 26

1. Name*

2. Job Role*

3. Do you have any new physical or mental health condition(s)which affects, or is likely to affect, your ability to carry out this role or carry out your normal day to day activities?*

YesNo

If yes, please specify

4. Do you have any changes to your current medical conditions which you need to make us aware of?*

YesNo

If yes, please specify

5. Do any of your current completed risk assessments require updating? If yes, please specify below, if not a reviewed risk assessment will be sent to you for signing.*

YesNo

If yes, please specify

6. Have you recently been prescribed new medication, which we need to be aware of?*

YesNo

If yes, please specify

7. Have you received any subsequent boosters in the last 12 months i.e. Covid19/flu?*

YesNo

If yes, please specify

8. If applicable, do you require any further adaptations to the ones already in place?*

YesNo

If yes, please specify

9. If you have circled any answers as Yes in response to the above questions, please give very brief details below setting out the nature of your condition, how it affects you now or how it may affect your ability to do your job.

The Company will process the personal data collected in connection with this questionnaire in accordance with its data protection policy, its policy on processing special categories of personal data and any internal privacy notices in force at the relevant time. Inappropriate access or disclosure of personal data will constitute a data breach and should be reported immediately to the Company’s Data Protection Officer Karen Beckett in accordance with the Company’s data protection policy. Reported data breaches will be investigated and may lead to sanctions under the Company’s disciplinary procedure.

If you have ticked ‘yes’ in relation to any of the above health questions, we may request your consent for a medical report so that we can better understand any workplace adjustments that are required, or how this information may impact any requirements of the role you have applied for.

Confirmation*

I confirm that the above information I have given is correct to the best of my knowledge.

Please verify that you are human*

Annual Healthcare Questionnaire