New Starter Food Handler Questionnaire

PART A to be completed by Recruiting Manager (please print)

Surname: ......
Date of Birth: ...... / First Name: ......
Job Title: ......

PART B to be completed by Employee

In order to ensure you are fit to work as a food handler, please read this form carefully and indicate if any of the conditions outlined below apply to you. If further assessment is required, it will be provided by Occupational Health at either the Gloucester or Cheltenham site. Any restrictions recommended are usually temporary and a follow-up assessment may be required.
DO NOT GIVE ANY HEALTH DETAILS ON THIS FORM
  • At present, or in the last 7 days, have you had
  • Diarrhoea and/or vomiting?
  • Stomach pain, nausea or fever?
  • Skin infections of the hands, arms or face?
Eg boils, styes, septic fingers, discharge from eye(s), ear(s), gum(s) or mouth
  • Jaundice (yellowing of the eyes or skin)?
  • Do you suffer from
  • A recurring bowel condition?
  • Recurring infections of the skin, ear(s) or throat?
  • Have you ever had Typhoid or Paratyphoid fever or are you now a known carrier of Salmonella Typhi or Paratyphi?
  • Are you are known carrier for any type of Salmonella?
  • In the last 21 days, have you had or been in contact with someone who has or may have had Typhoid or Paratyphoid?

I can confirm that NONE of the above conditions apply to me

I can confirm that one or more of the above conditions apply to me.

DECLARATION

I confirm that I have read and understood the above information. I understand that I have a responsibility to report immediately to my Manager if I have any of the following symptoms or conditions:

Diarrhoea and/or vomiting?Stomach pain, nausea or fever?

Skin infections of the hands, arms or face?Contact with any infectious diseases?

An accident at work

Employee’s signature: ......
Contact Tel. No. Home: ...... / Date: ......
Mob: ......

Please return this form to your recruiting manager who will forward it to Working Well Occupational Healthfor further assessment, if appropriate. A copy of this form will be kept on your personal file.