Page 1 to Be Completed by the Appointing Officer Before

PAGE 1 TO BE COMPLETED BY THE APPOINTING OFFICER BEFORE

THE FORM IS GIVEN TO THE APPLICANT

ALL BOXES MUST BE COMPLETED - INCOMPLETE FORMS CANNOT BE PROCESSED

APPLICANT DETAILS

APPOINTING OFFICER DETAILS - for response and all correspondence

Job & Task Analysis - please ü where appropriate

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TO BE COMPLETED BY THE APPLICANT:

All information in this questionnaire is confidential to the Occupational Health Service and will be examined by an occupational health nurse adviser or doctor. If there are any queries regarding your response you may be asked for further information and/or to attend for a health interview. Depending on the job you are applying for you may have to undergo specific screening prior to taking up the post.

The information you supply will be used to determine your fitness to take up the post and advice on this will be supplied to the appointing officer. No detail regarding your health will be released without your consent but advice may be given on reasonable adjustments if appropriate. It is important that you give accurate information as failure to do so could put you or others at risk.

Before completing the health questionnaire please give details of your employment in the lat ten years in chronological order, most recent first.

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HEALTH QUESTIONNAIRE:

Please answer the following questions giving as much detail as possible, including dates

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Please give details of sickness absence from work/college/school in the past 3 years

Approximate date Reason for absence Length of absence

of absence

I confirm the information I have given on this form is complete and true to the best of my knowledge

Please return your completed and signed form direct to:

Occupational Health Department

137 Newhall Street

Birmingham B3 1SF

Do not return to employment department

Please do not include any other documentation

Information recorded on this form and any reports, recommendations and correspondence arising from the information on this form will be processed and archived by Birmingham City Council in accordance with the Data Protection Act and Access to Medical Reports Act.

For Occupational Health use only

Result - Fit for proposed job

Fit with adjustments/restrictions

Unfit

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