Confidential
STRICTLY CONFIDENTIAL
www.luxurycare.co.uk
“luxury care in a luxury Environment”
PRE-Employment Health Questionnaire
The purpose of this questionnaire is to determine your fitness for the post you have applied for with Luxurycare.co.uk and to advise management of any reasonable adjustments (measures needed to support you in this post if you have a disability which falls within the Disability Discrimination Act 2005). It will be retained confidentially on your Employee File in accordance with the principles of the Data Protection Act 1998. The form can also be used for those who are or have started employment with Luxurycare.co.uk. The Questionnaire consists of 2 parts, Part A which contains a Health Declaration, and Part B. N.B. Part B should only be completed if you are unable to sign the declaration in Part A.
Please complete the form in black ink and CAPITAL letters.
PART A – Please complete fully.
PERSONAL DETAILS Title: Surname: Forenames: Date of birth: Address:
Day contact phone /mobile no: E mail address JOB DETAILS Proposed job title / occupation: No. of hours of work per week: Work location: Name of your Manager
1
STRICTLY CONFIDENTIAL PART A continued Does the job involve the following? Please tick all that apply. Manual work Driving a company vehicle Working in a noisy environment Working with machinery/plant Working at night Working with children Working with vulnerable adults EMPLOYMENT HISTORY Are you currently employed by Luxurycare.co.uk? If so when did you commence your current post? Where are you based? What is your job title? Have you previously been employed by Luxurycare.co.uk? If so when did you leave? Where were you based? What work did you do? Yes/No Date: Handling food Lifting heavy loads Use of display screen equipment Exposure to harmful substances Working at times in a confined space Performing emergency procedures Performing fire drill
Yes/No Date:
Please sign and date below if this declaration is
www.luxurycare.co.uk
“luxury care in a luxury Environment”
PRE-Employment Health Questionnaire
The purpose of this questionnaire is to determine your fitness for the post you have applied for with Luxurycare.co.uk and to advise management of any reasonable adjustments (measures needed to support you in this post if you have a disability which falls within the Disability Discrimination Act 2005). It will be retained confidentially on your Employee File in accordance with the principles of the Data Protection Act 1998. The form can also be used for those who are or have started employment with Luxurycare.co.uk. The Questionnaire consists of 2 parts, Part A which contains a Health Declaration, and Part B. N.B. Part B should only be completed if you are unable to sign the declaration in Part A.
Please complete the form in black ink and CAPITAL letters.
PART A – Please complete fully.
PERSONAL DETAILS Title: Surname: Forenames: Date of birth: Address:
Day contact phone /mobile no: E mail address JOB DETAILS Proposed job title / occupation: No. of hours of work per week: Work location: Name of your Manager
1
STRICTLY CONFIDENTIAL PART A continued Does the job involve the following? Please tick all that apply. Manual work Driving a company vehicle Working in a noisy environment Working with machinery/plant Working at night Working with children Working with vulnerable adults EMPLOYMENT HISTORY Are you currently employed by Luxurycare.co.uk? If so when did you commence your current post? Where are you based? What is your job title? Have you previously been employed by Luxurycare.co.uk? If so when did you leave? Where were you based? What work did you do? Yes/No Date: Handling food Lifting heavy loads Use of display screen equipment Exposure to harmful substances Working at times in a confined space Performing emergency procedures Performing fire drill
Yes/No Date:
Please sign and date below if this declaration is