Before completing this form, please read the accompanying guidance notes. Please write clearly in black ink or type.

CONFIDENTIAL

1. PERSONAL DETAILS


2. GENERAL PRACTITIONER’S DETAILS


3. EQUALITY ACT 2010


The Equality Act 2010 defines a person with a disability as “A physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.”

4. PAST MEDICAL HISTORY


5. SICKNESS ABSENCE

Please list how many days you have been absent from work, school, college etc in the last three years due to sickness. For each absence please also indicate the dates and the reason.

6. DECLARATION


I declare that the information given in this questionnaire is true and complete. I understand that any misleading information or any omissions will be sufficient grounds for termination of my employment. I will notify you immediately if any of my answers change on my completed questionnaire. I do/do not give permission to my General Practitioner to disclose relevant information to the HR department in accordance with the Access to Medical Records Act 1988. I do/do not wish to see my General Practitioner’s comments before the questionnaire is returned to the HR manager. I do/do not want to know if I am at risk of early ill-health retirement.

The information provided by you on this form as an applicant will be stored either on paper records or a computer system in accordance with the Data Protection Act 1998 and will be processed solely in connection with the recruitment process.

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