Pre-Employment Health Questionnaire

The purpose of this pre-employment questionnaire is to establish:

• that you are medically fit for the job you have applied for
• that you are able to give regular and effective service
• that you can carry out the job without any undue risk to the health and safety of yourself and others
• a baseline for future occupational health records
• if any workplace modifications or adjustments are required due to a disability

It is important you answer the questions as clearly and as accurately as possible, giving details for any ‘yes’ answers.

Please note that we may contact you by phone to do a brief telephone consultation to clarify any details you have provided on this form.

Data Protection Notice

The completed questionnaire will be stored in either electronic or paper form by the Civil Service Occupational Health Department in accordance with the Data Protection Legislation. The medical information supplied will be treated in strict confidence and will not be disclosed to any third party without your consent. Any advice given to the employing department / authority and / or personnel / human resources will be in general terms only. Information gathered may be disclosed on an anonymous basis in a group format for research purposes. This record may be accessed by you under data protection legislation.