1.

Do you have or have you ever had any significant health problem, impairment / disability (physical or mental) or learning difficulties that may affect your ability to undertake the tasks set out in the job description of the post offered?

2.

Do you have or have you ever had any illness, impairment of disability that may have been caused or made worse by your work?

3.

Have you ever left or been denied employment in an organization on the grounds of ill health or been medically retired on the grounds of ill health?

4.

Are you having, or waiting for any medical treatment or investigations at present?

5.

Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?

1.

I confirm that the information given above is complete and correct, I understand that any incomplete, untrue or misleading information given to will entitle the employer to reject my application, withdraw any offer of employment, or, if I am employed, dismiss me without notice.

2.

By my signature, I give authority to the employer to contact my GP for further details regarding any of the potential health problems I have declared above.

3.

I agree that reserves the right to require me to undergo a medical examination to assess my suitability for work.

4.

I do not wish to complete the questionnaire, and I do not wish to have a free health assessment.

5.

Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?