Strictly Education - Placement Questionnaire
The information given by you on any part of this form will be used as the basis of
a medical opinion given by Medigold Health when assessing your fitness and
suitability for the post you have been offered. Please answer all the questions as
fully as possible.
PERSONAL DETAILS
Title
Mr
Forename
Haris
Surname
Ali
Date of birth
02/07/1990
Address
28-32 Pembridge Gardens, Nottinghill
Town
London
Postcode
W24DX
Telephone
07539426465
Mobile
07539426465
Email
hars9595@gmail.com
Candidate ID
What position have you been offered (as stated in contract of employment):
Science Teacher
School Name
Ashbourne College
Manager's Email Address
hien@ashbournecollege.co.uk
SECTION 1 - GENERAL
Do you suffer from any medical condition, that you feel you would need
support with in order to carry out functions which are essential to your
proposed employment?
No
Are you currently receiving any treatment or investigations for any
condition?
No
Are you taking any medication which makes you drowsy or has any other
side effects?
No
Do you require any adjustments to be made to your work or work
environment due to a medical condition?
No
Are you taking any medication?
No
Have you been treated for alcohol related problems or advised to reduce
your alcohol intake within the last 24 months?
No
Have you used any drug of abuse (not alcohol or tobacco) within the last 24
months?
No
Have you been treated for drug related problems within the last 24 months?
No
Do you have or are you currently being investigated for a learning difficulty
(i.e. dyslexia, dyspraxia, ADHD)?
No
Were you absent more than 10 days due to a medical condition or
conditions over the last 12 months?
No
SECTION 2 - RESPIRATORY
Do you suffer from any respiratory condition, including obstructive sleep
apnoea syndrome?
No
Do you require any medical support with regard to a respiratory condition?
No
From your knowledge of the job that you will potentially be doing, is there
anything that you feel may impact on your medical condition?
No
Do you have any allergies?
No
Are there any adjustments that you feel would be required to allow you to
undertake your potential role without impacting on your medical condition?
No
SECTION 3 - VISION
Do you have any visual deficits that are not corrected with glasses/contact
lenses?
No
Have you been diagnosed as having a colour deficit (colour blind)?
No
Do you have any visual deficits that you feel would impact on any intrinsic
functions of your role?
No
SECTION 4 - HEARING
Do you have a hearing deficit?
No
HEARING (Not Applicable)
SECTION 5 - SKIN
Do you suffer from any skin conditions, i.e. eczema, psoriasis, etc?
No
From your knowledge of the job that you will potentially be doing, is there
anything that you feel may impact on your skin condition?
No
Are there any adjustments that you feel would be required to allow you to
undertake your potential role without impacting on your medical condition?
No
SECTION 6 - NEUROLOGY
Do you suffer from any neurological or brain related condition?
No
Do you suffer from any condition that causes you to lose consciousness?
No
Do you suffer from blackouts, epilepsy or any condition that would pose a
safety risk to either yourself, colleagues or the general public?
No
Do you have any restriction on driving imposed by the DVLA?
No
SECTION 7 - PSYCHOLOGICAL HEALTH
Within the last 5 years have you suffered from any psychological condition
including depression, anxiety, panic attacks or other stress related
illnesses, requiring medication or other forms of treatment?
No
Have you ever had suicidal thoughts that required medical intervention?
No
Have you ever been diagnosed with an eating disorder?
No
Have you ever self harmed?
No
Do you feel that you require any adjustments in relation to a psychological
condition to enable you to undertake your potential role?
No
Are there any factors that you feel would impact on your ability to undertake
your potential role?
No
SECTION 8 - MUSCULOSKELETAL
Within the last 5 years have you suffered from any medical conditions that
affect your muscles, ligaments or joints that may impact on your ability to
undertake any aspect of your potential role?
No
Do you feel that you require any adjustments in relation to a
musculoskeletal concern to allow you to undertake your potential role?
No
From your knowledge of the job that you will potentially be doing, is there
anything that you feel may impact on your medical condition?
No
DECLARATION
I hereby declare to the best of my knowledge and belief that the above
answers are true. I realise that any false or misleading statements within
this questionnaire may result in action being taken against me, which may
ultimately result in my dismissal under the appropriate organisational
procedure. I understand that advice will be given to management by the
Organisation's Occupational Health Clinicians and that only appropriate
medical information supplied by me, either verbally or written, which will
enable my employers to support me in my role or to enable them to make
reasonable decisions and adjustments will be divulged by the clinician to
my employer.
Yes
It may be necessary for you to be contacted for more information. Please note that we
will make two attempts to contact you. If contact is not made after the second call, we will
close the process. You may be requested to attend an appointment with an Occupational
Health Clinician.
Medigold Health is committed to the principles and requirements to both the
Access to Medical Reports Act 1988 and the General Data Protection Regulation
and hold the necessary notification and registration for the processing of your
data.
Medigold © 2024
