Employee Starter Form
Employee Starter Form

    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
    Allergies including drugs, food or other substances
    Asthmas, hay fever, bronchitis, tonsillitis, sinusitis
    Tuberculosis
    Heart or circulatory trouble
    Raised blood pressure
    Blackouts, epilepsy, fainting attacks or giddiness
    Nervous, mental disorders or 'nerves'
    Diabetes, thyroid or other 'gland' trouble
    Varicose veins
    Rupture, stomach or bowel problems
    Pain or injury to back
    Pain or injury to any other joint or muscle (incl rheumatism / arthritis)
    Ear disease, discharge or deafness
    Do you wear a hearing aid?
    Eye defects or injury
    Do you wear spectacles / contact lenses?
    Chest X-ray in the past year
    Any operations
    Any other medical condition or illness involving time off work/school
    Have you ever been employed in Local Government, if so, where and when
    Do you smoke? If so how many per day
    FEMALES ONLY - Painful or heavy periods?

    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?
    If Yes, please give details:
    Have you stayed away from work or school during the past 12 months?
    If Yes, please give details:
    Have you any disability or are you registered disabled?
    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.
    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
    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.

    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

    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?
    Did you complete or leave your studies before 6th April?
    Are you repaying your Student Loan directly to the Student Loans Company by direct debit?
    What type of Student Loan do you have?

    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?
    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?
    Are you repaying your Postgraduate Loan direct to the Student Loans Company by direct debit?

    Declaration

    I confirm that the information I’ve given on this form is correct

    Full Name
    Email Address

    Request Callback

      Your Name*

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      Best Time To Call*

      Contact Us


      Corby Business Centre, Eismann Way, Corby, NN17 5ZB
      Tel: 01536 639 028 
      Mobile: 07865504780
      Email: info@rdcare.co.uk