Non-Safety Related Worker Questionnaire

 I declare that the information I have provided in this form is true and complete to the best of my knowledge.  I understand that I may be asked to attend a medical examination with an occupational health professional and that I consent to undergo such a medical examination, if required.  I understand that failure to disclose all health information in a health assessment or questionnaire situation may result in your employer withdrawing the offer of employment / or an investigation which may lead to a disciplinary hearing  I have been informed of the nature of the assessment and the records that will be kept. I confirm that I have been advised regarding the purpose of this health assessment by the Occupational Health professional and consented to undertake the appropriate surveillance on this date and the outcome regarding suitability to be shared with the designated HR or H&S contact within the employing company I understand that this may include any recommendations such as further training, reasonable adjustments or further investigations etc and as may be required and that if required this information will also be shared with the relevant enforcing authorities.  In signing this form, I confirm my explicit consent within the meaning of the Data Protection Act 1998 for the Occupational Health Service Provider to process my personal information which includes computerising my personal and medical information. I understand that my information will be held securely and if I wish to gain access to my medical information I can do so by requesting it in writing.