Health and Fitness Questionaire

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? *

Yes

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

Yes

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? *

Yes

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

Yes

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? *

Yes

If you answered yes to any of the above questions, please provide details below: *

Applicants Declaration

Read and understand before signing *

1. I confirm that the information given above is complete and correct, and that I understand that any incomplete, untrue or misleading information given to Academy Care will entitle the employer to reject my application, withdraw any employment offer made, 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 Academy Care 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.

Forename *

Surename *

Your signature *

clear

Todays date * +

Document Version: 1.2

Last reviewed: 14/08/2023

Reviewed by: Kristian H