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Acquired or Traumatic Brain Injury
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Candidates
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Supporting Our Official Charity Partner
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Refer a Friend Scheme
Care Packages for Brain and Spinal injury
Contact Us
Home
About Us
Our Official Charity Partner
Meet the Team
Clients
Testimonials
Acquired or Traumatic Brain Injury
Spinal Injury
Other Medical Conditions
Live Vacancies
Register CV
Candidates
Apply online
Supporting Our Official Charity Partner
Subject Access Requests
Refer a Friend Scheme
Care Packages for Brain and Spinal injury
Contact Us
Pre-Employment Health Declaration
Pre-Employment Health Assessment Form
Your appointment is subject to an assessment of your fitness for this work. The purpose of this is to identify any health problems or disabilities that may affect your ability to do certain aspects of the role you have applied for and enable us to assess what adjustments to the role may be needed to enable you to work, if you have a health problem or disability.
Name
*
First
Last
Date of Birth
*
Date Format: DD slash MM slash YYYY
Address
*
Street Address
Address Line 2
City
ZIP / Postal Code
Phone Number
*
Email
*
GP Practice
*
GP Contact Number
*
Please read the following questions carefully
To preserve medical confidentiality you are not required to identify any conditions/illnesses you may or may not have on this form.
Do you have any condition or disability that could affect your ability to undertake any of the activities of the proposed post, including shift patterns, without adjustments?
*
Yes
No
Please provide additional information
Have you ever had any illness / impairment / disability which may have been caused or made worse by your work?
*
Yes
No
Please provide additional information
Has your work (hours or duties) ever been modified or have you had to leave a job because of a health problem?
*
Yes
No
Please provide additional information
Have you ever been affected by one of the following health problems:
*
Diabetes?
Epilepsy?
Musculoskeletal problems or back pain?
Skin disorders? (Eg. Hand Eczema)
Chest problems? (Eg. Asthma)
Heart, circulation or blood pressure problems?
Impairments of vision? (Other than to wear glasses)
Impairments of hearing?
Depression, psychiatric or nervous/ stress problems?
Substance or alcohol misuse?
Any other problem/s you may wish to mention?
None
Please provide additional information
Consent
*
In signing this questionnaire you confirm that all the information provided is true to the best of your knowledge and correct. If it is subsequently shown that information has not been disclosed by you, or has been misleading or false, the offer of employment may be withdrawn.
I undertake to submit, if required, to a further assessment by Libertatem Healthcare Group clinical staff or an appointed Occupational Health Nurse.
In signing this form, I confirm my explicit consent within the meaning of the General Data Protection Regulations 2018 for Libertatem Healthcare Group to process my personal information which may include electronic storage of my personal information. I understand that my information will be held securely and if I wish to gain access to my information I can do so by requesting it in writing.
Signature
*
Phone
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