Staff Medical Questionnaire Email Date of Birth Surname Gender MaleFemale Forenames Proposed Job Title Mobile Telephone Address Summary Please answer all questions (delete Yes/No) Have you ever had: Dermatitis or skin trouble YesNo Allergies including drugs, food or other substances YesNo Asthmas, hay fever, bronchitis, tonsillitis, sinusitis YesNo Tuberculosis YesNo Heart or circulatory trouble YesNo Raised blood pressure YesNo Blackouts, epilepsy, fainting attacks or giddiness YesNo Nervous, mental disorders or 'nerves' YesNo Diabetes, thyroid or other 'gland' trouble YesNo Varicose veins YesNo Rupture, stomach or bowel problems YesNo Pain or injury to back YesNo Pain or injury to any other joint or muscle (incl rheumatism / arthritis) YesNo Ear disease, discharge or deafness YesNo Do you wear a hearing aid? YesNo Eye defects or injury YesNo Do you wear spectacles / contact lenses? YesNo Chest X-ray in the past year YesNo Any operations YesNo Any other medical condition or illness involving time off work/school YesNo Have you ever been employed in Local Government, if so, where and when YesNo Do you smoke? If so how many per day YesNo FEMALES ONLY - Painful or heavy periods? YesNo If you have answered YES to any of the above questions. Please fill in the details below: Condition/Illness Approximate Care Treatment/duration Are you at present on any medical treatment – injections, or tablets or have you been during the last 12 months? YesNo If Yes, please give details: Have you stayed away from work or school during the past 12 months? YesNo If Yes, please give details: Have you any disability or are you registered disabled? YesNo If Yes, please give details: Do you give permission to communicate with your general practitioner or other medical attendant if necessary? This information is confidential to the Occupational Health Department. YesNo Name of General Practitioner Address of General Practitioner Phone Number I declare that I have answered all questions honestly and completely to the best of my knowledge and I am not aware of any other physical or mental disability which will affect my employment. Name Date Next of Kin Details Employee’s Name Contact Person (in emergency) Relationship to Yourself HusbandWifePartnerMotherFatherBrotherSisterDaughterSonOther RelativeOther Next of Kin Address Next of Kin Home Phone No. Next of Kin Work Phone No. Next of Kin Mobile Phone No. Nomination Form for Death Benefits To the Trustees: Please note that I wish the Trustees to consider distributing the benefits payable under the Scheme on my death as follows:- NAME ADDRESS RELATIONSHIP % 1 2 3 4 I understand that this nomination is no way binding on the Trustees and that I may alter the nomination, in writing, at any time. This nomination form cancels any previous nomination form which I may have completed in relation to the Scheme. Name Department Date Bank Details I authorise you to pay my Monthly Salary/Wages directly into my bank / building society account. These details shall remain in force until cancelled by me in writing. Name Bank Name Payroll No. Branch Bank Sort Code Address: Account No. Account Name Building Society Roll No. Post Code N.I.No. Date of Birth Disclosure of Criminal Convictions On appointment we ask you to disclose any ‘unspent’ criminal convictions you have in line with the Rehabilitation of Offenders Act 1974. Any information given about convictions will be completely confidential and will be considered only in relation to the job for which you are applying. The number of people rejected for employment who disclose a conviction is very small. It is very serious if you wilfully conceal convictions. Question: Have you ever been convicted of any offence in any court of the UK or elsewhere other than a motoring offence not resulting in disqualification? Please note that convictions which are ‘spent’ under the Rehabilitation of Offenders Act 1974 should be disclosed by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Guidance notes on ‘spent’ convictions are overleaf for your information. YesNo If YES, please provide details below Employee Statement Choose the statement that applies to you, either A, B or C, and tick the appropriate box. Statement A Statement B Statement C Do not choose this statement if you’re in receipt of a State, Works or Private Pension. Choose this statement if the following applies. This is my first job since 6 April and since the 6 April I’ve not received payments from any of the following: Jobseeker’s Allowance Employment and Support Allowance Incapacity Benefi Do not choose this statement if you’re in receipt of a State, Works or Private Pension. Choose this statement if the following applies. Since 6 April I have had another job but I do not have a P45. And/or since the 6 April I have received payments from any of the following Jobseeker’s Allowance Employment and Support Allowance Incapacity Benefi Choose this statement if you have another job and/or you’re in receipt of a State, Works or Private Pension Statement A applies to me Statement B applies to me Statement C applies to me Student Loan For more guidance about repaying, go to www.gov.uk/repaying-your-student-loan Postgraduate Loan For more guidance about funding and repaying, go to www.gov.uk/funding-for-postgraduate-study For more guidance for employers, go to www.gov.uk/guidance/special-rules-for-student-loan Do you have one of the Student Loan Plans described below which is not fully repaid? YesNo Did you complete or leave your studies before 6th April? YesNo Are you repaying your Student Loan directly to the Student Loans Company by direct debit? YesNo What type of Student Loan do you have? YesNo Student Loan Plans You’ll have a Plan 1 Student Loan if: you lived in Scotland or Northern Ireland when you started your course (undergraduate or postgraduate) you lived in England or Wales and started your undergraduate course before 1 September 2012 You’ll have a Plan 2 Student Loan if: you lived in England or Wales and started your undergraduate course on or after 1 September 2012 your loan is a Part Time Maintenance Loan your loan is an Advanced Learner Loan your loan is a Postgraduate Healthcare Loan Do you have a Postgraduate Loan which is not fully repaid? YesNo You’ll have a Postgraduate Loan if: you lived in England and started your Postgraduate Master’s course on or after 1 August 2016 you lived in Wales and started your Postgraduate Master’s course on or after 1 August 2017 you lived in England or Wales and started your Postgraduate Doctoral course on or after 1 August 201 Did you complete or leave your Postgraduate studies before 6th April? YesNo Are you repaying your Postgraduate Loan direct to the Student Loans Company by direct debit? YesNo Declaration I confirm that the information I’ve given on this form is correct Full Name Email Address Δ
