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This questionnaire collects specific job-related information about a post, and relevant health information about the new starter. This information can then be assessed by OHS advisers or other qualified personnel, who can:
Assess the candidate's medical capability to do the job for which they have applied: this will include assessing whether there are any statutory and legal reasons why an individual may not carry out particular work: for example, health and safety regulations would mean that a candidate with epilepsy would not be allowed to undertake a post involving driving; and
Provide advice to departments to ensure that none of the role's duties will adversely affect any pre-existing health conditions the candidate has declared.
How long to understand and implement this form?
10 mins
How many words in this form?
969
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What is a Pre-employment medical questionnaire form?
The purpose of this Pre-employment medical questionnaire form is to provide you with a flexible and customisable document to serve as a robust and effective starting point for you.
By using our Pre-employment medical questionnaire form, you can streamline your process, maintain consistency and accuracy, and save time, and it can be easily adapted to fit your specific scenario.
In which jurisdictions can this form be used?
Great Britain & NI (United Kingdom), Worldwide
Pre-employment medical questionnaire
[Employees starting jobs that involve work with hazards (e.g. sensitising chemicals, allergens etc) or safety-critical activities (e.g. night work, driving a vehicle etc) must complete and return this medical questionnaire before commencing employment.]
An answer must be provided for all questions. The information will be treated in confidence by the Occupation Health Adviser.
PLEASE COMPLETE IN CAPITAL LETTERS
Personal details
Title:
Mr | Mrs | Ms | Mx | Dr | Other
Full Name:
Address:
Contact telephone:
Date of birth:
GP details
GP name:
Address:
Telephone:
Position applied for:
Occupational hazard history
Please note the job titles, dates, and nature of any known hazards to which you have been exposed.
Medical history
Please complete the following questions by ticking the appropriate box. If the answer is yes, give details including (a) date, (b) amount of time lost from work/school, (c) treatment, as appropriate.