This form asks questions about your employment history, past and present health. It will be used to make an assessment of your health in relation to your employment. This Pre-Placement Health Questionnaire will stay within Occupational Health, however a fitness report based on the information disclosed in this form will be sent to Management and/or Human Resources. An Occupational Health Advisor may contact you by telephone to discuss any health issue you have disclosed in greater detail if necessary.
I declare that the information given in this document is true, accurate, complete and to the best of my knowledge. I understand that failure to disclose information could affect my employment and could put my health and the health of others at risk. I consent to a telephone and / or face-to-face consultation and if necessary a medical interview and examination. I understand that now, and in the future, I have a duty to report the development of any health condition(s), or medication(s), which could affect safety, concentration or performance at work.
I consent for my company to add my personnel record to the Constructing Better Health (CBH) database* (where applicable).
I consent for the results of my health screening to be uploaded to the OH database. I understand that my employer will only be able to see my medical outcome, medical expiry date and any recommendations. I am aware that they will not see any medical/clinical information.
I consent to personal information and the results of screening (occupational health records) to be stored as hard copy and on secure computer systems accessible only to KML Occupational Health professionals.
I understand that KML OH have a duty to report any relevant health concerns to my Sentinel sponsor, and this may impact on my existing Sentinel competencies. (Where applicable)
I understand that I have the right to apply for access to health information held about me, under ‘’subject access rights’’ outlined in The Data Protection Act 1998. Please contact KML OH.
Please note: for directly employed personnel, it is unlawful for the prospective employee to be asked to complete a new starter questionnaire until the job offer has been made in writing.