Fitness to work

Broomwood / Fitness to work

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Personal Information

Name

Phone

Gender

Nationality

Address & Postcode

Do you have any medical conditions?

Do you have any physical or mental impairment that could be classed as a disability under the Equality Act 2010?

If you have answered yes to the above question, please could you give brief details below:

Do you regularly take tablets or medicine?

If so, what do you take?

Declaration

I am willing to undergo a medical examination if required and I declare that the information I have given on this form is correct to the best of my knowledge.

Data Protection

The organisation treats personal data collected in this medical questionnaire in accordance with its data protection privacy policy. Information about how data is used and the basis for processing the data is provided in the organisation's job applicant privacy notice.

Signature

Clear Signature

Date