Please complete this form.
All the information on the form will be treated in strict confidence and will not be divulged to any third party without written consent.
Please answer all of the following questions. If you answer Yes please give details.
Have you ever had or do you have now, any of the following?
You have a duty to report to your employer of any changes to your health.
Certain jobs carry with them a risk of infection. In such cases we offer the facility of being
immunised to prevent the risk of infection. Please provide details below of your immunisation
history. When attending, please bring with you proof of identity e.g. passport or hospital
Blood test results
The company operates a policy of non-discrimination. In line with company policy, and National Guidelines, 'HSC 1998/226 - Guidelines on the Management of AIDS/HIV Infected Health Care Workers and Patient Notification' (updated August 1999), you must inform the Director of Training and Quality if you know or suspect you are HIV positive or have an AIDS defining illness. This information is necessary in order that a Risk Assessment may be undertaken to your safety and that of others.
If you know or suspect you are either HIV antibody positive or have AIDS, please tick the appropriate box. This information is absolutely confidential to the Director of Training and Quality.
The following section is to be completed only by those members of staff who regularly undertake night duty.
Have you suffered from and been treated for any of the following. If Yes, please give details of the condition and whether they are ongoing at present.
I declare that the information on this form is true to the best of my knowledge. Further, I understand that if I should be found to knowingly make a false statement regarding my medical history either in answering the above questions or to the Company's Director of Quality and Training, or should I conceal any material fact, the Company can terminate my contract without notice.