#35671 - Sensible Risk

Pre-Employment Questionnaire

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Choco Bloc Manufacturing Lesserpool

Form to be seen and a response obtained from the Health and Safety Advisor

Please complete and respond to this form as directed. The health of each candidate is considered individually and no decision to reject a candidate on medical grounds will be made without a medical examination or medical advice being sought. You should notify us immediately if you have any serious illness after completing this form and before you take up the appointment offered as a result of your application. If you give any information that you know is false – or you withhold any information – your application may be rejected (or, if already appointed, you may be dismissed).

Section 1 To Be completed by the employer

Company Choco Bloc Manufacturing Department Operations

Name of person responsible for recruitment Miss K. Eepatwork

Name and contact telephone number of Miss. K Eepatwork person to whom medical clearance should be returned 01876 543345

Job title/positions applied for

Typical tasks associated with this job

In which department will the employee be working? Operations

Proposed date of joining company? To be arranged.

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Section 2 To be completed by potential employee

Fore name Alan A Jobby Date of Birth 28th June 1965

Address 18 Downhidden Lane Lesserpool

Gender* Male/Female Contact Tel Number 07890 223 224

Name and Address of GP Dr. D.I.Spensing Epidermis Way Lesserpool Do you give permission for our Occupational Health Staff to contact your GP*

YES NO

Section 3 Medical History Questions

Do you give consent for this information to be shared with the Company Health and Safety Team*

YES NO

Do you, or have you ever suffered from any of the following: (For questions 3.1 to 3.12 inclusively, indicate if you have you ever suffered from any of the following conditions by underlining the appropriate condition and providing details in the comments

3.1 tuberculosis, pleurisy, asthma, bronchitis, or any other lung, throat or ear complaint, including deafness

YES NO

3.2 any disorder of the heart, circulatory system, high blood pressure

YES NO

3.3 persistent indigestion, gastric or duodenal ulcer, intestinal complaint or rupture

YES NO

3.4 epilepsy or fits YES NO

3.5 any psychological or nervous complaint YES NO

3.6 diabetes, gout or any kidney or bladder complaint YES NO

3.7 any arthritis, slipped disc, rheumatism, back trouble or upper limb problem

YES NO

3.8 dermatitis, other skin complaint or allergic condition YES NO

3.9 sleep apnoea, narcolepsy or cataplexy YES NO

3.10 frequent headaches or migraine YES NO

3.11 any eye complaint including blurred vision or eye discomfort YES NO

3.12 any other significant medical problem? (excluding coughs/cold/flu or any of the conditions listed above)

YES NO

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Section 3 Medical History Questions (Continued)

3.13 Do you have any difficulty in recognising different colours? YES NO

3.14 Have you ever failed a medical examination of any kind? YES NO

3.15 Have you ever consulted, or been recommended to consult a medical specialist?

YES NO

3.16 Have you ever been in hospital as a patient? (Please provide details on page 4)

YES NO

3.17 Are you currently on any treatment being prescribed by a Doctor?

YES NO

3.18 With reference to the Equality Act 2010, do you have any physical or mental impairment, which significantly affects your daily living?

YES NO

(If you answer ‘Yes’ to question 3.18, you may be sent a supplementary health questionnaire for completion so that the medical staff can assess appropriate and reasonable work adjustments for you)

SECTION 4 – OCCUPATIONAL HISTORY/DETAILS Have you ever worked :

4.1 in a dusty environment?’ YES NO

4.2 in a noisy environment?’ YES NO

4.3 with chemicals YES NO

4.4 with vibrating tools?’ YES NO

For questions 4.5 to 4.10 inclusive – ‘Have you ever …

4.5 had a repetitive strain injury or an upper limb problem?’ YES NO

4.6 had any problems related to alcohol?’ YES NO

4.7 had any problems related to the use of illegal or prescribed drugs?’

YES NO

4.8 had any disease or injury arising out of your work e.g. deafness, backache, dermatitis, asthma or vibration white finger?’

YES NO

4.9 been advised for medical reasons not to do night work, shift work, or any other kind of work?’

YES NO

4.10 undergone health surveillance due to hazards in your previous job?’

YES NO

4.11 had a driving licence withdrawn or special conditions imposed YES NO

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If you have answered “yes” to any question on pages 2 or 3 of this questionnaire, please give details in the space below, continuing on a separate sheet of paper if necessary, and include: the date that the problem occurred and whether the condition is still present and details of any medication used or treatment undertaken in connection with the condition, and details of any other medical condition not referred to within this questionnaire. 3.2 I suffer from high blood pressure and am currently taking aspirin and atenolol to control the condition I suffer from varicose veins which have received surgical treatment. There is a recurrence of the presence of varicose veins in my left leg, standing for extended or prolonged periods causes swelling in the left leg. 3.5 I had a skin condition previously due to being diagnosed a “Nerve” problem. 3.8 I had a skin condition previously due to being diagnosed a “Nerve” problem. This consisted of an itchy skin for which a cream sorted me out. I have suffered from dermatitis caused by exposure to greases in a past employment. Provision of protective gloves has prevented a repeat of episodes of ill health caused by this problem. It was initially treated with a steroid cream.

3.12 I suffer from sinusitis and have had surgical intervention to the sinuses as they were cauterised. This has not been successful. When exposed to dusty environments without nasal protection I find that the sinusitis does return.

3.16 I was admitted to hospital following a blow to the head when playing rugby 3.18 If required to carry heavy parcels frequently, back pain returns. Standing for long periods does make the varicose veins swell up. 4.5 I have had surgical repair of a by lingual hernia. I sometimes get lower back pain but have always manage to attend work. I have had no instances of absence caused by the hernia. I have had no instances of absence for more than a three days because of pain and mobility problems caused by the lower back pain.

Section 5 Declaration

PLEASE READ CAREFULLY. By signing this declaration you will be giving your consent to the processing of the information you have supplied. If you do not understand the content of this form, the content or the effect of the declaration or you feel unable to give your consent, please contact the person responsible for recruitment mentioned on part 1 for further information. I CONFIRM THAT I HAVE READ AND UNDERSTOOD THE DATA PROTECTION NOTICE ABOVE. I HEREBY AGREE AND CONSENT TO THE PROCESSING OF THE INFORMATION THAT I HAVE SUPPLIED ABOUT ME. I declare that all the foregoing statements are true and complete to the best of my knowledge and belief and I am not aware of any other medical condition not referred to elsewhere in this questionnaire. I understand that any misrepresentation will invalidate my application and if employed, could lead to my dismissal. I understand that I may be required to undergo a medical examination by the company’s appointed medical adviser for pre-employment purposes only.

Your Signature N.A.Jobby Date 31st August 2018