Medical Questionaire

Any information disclosed on this form will be shared with the employer.

It is important that you tell us about any illness, injury or other medical condition that may affect your safety or the safety of others, and/or the ability to work with/handle food.

Please answer the below questions honestly/fully and provide any further details that may be requested and read through the whole form.

1. Do you have any disability or health issues that may make it difficult for you to carry out functions which are intrinsic to the role you seek?(Required)

Yes

2. Are there any reasonable adjustments you require to carry out your duties safely?(Required)

Yes

If answered ‘yes’ to any of the above questions, please ensure additional information is provided below:

I declare that all the above statements are true and complete to the best of my knowledge. I know of no medical reason that would impair my ability to work and why I should not work in any environment related to food. Should the situation change, I will immediately notify KSB Recruitment Consultants Ltd either whilst I am:

Engaged on a temporary assignment by KSB Recruitment Consultants Ltd or
In-between assignments for KSB Recruitment Consultants Ltd

I understand that any deliberate misrepresentation may result in disciplinary action. I am aware that I must immediately inform the manager if any of the above changes or if I develop any kind of medical condition that may affect my ability to work.

ACTION NEEDED:

Please sign and date below to confirm that you have read and completed this form to the best of your knowledge.

Full Name(Required)

Email(Required)

Signature(Required)

Date(Required)