Medical Questionaire

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. Are you or have you ever been a carrier of, enteric fever (typhoid or paratyphoid, or any other form of food poisoning or food borne disease)?(Required)

Yes

2. Have you now, or have you over the last seven days, suffered from diarrhoea and/or vomiting?(Required)

Yes

3. Have you been abroad in the last three weeks, and suffered any illness?(Required)

Yes

4. At present, are you suffering from: Skin trouble affecting hands, arms or face? Boils, sties or septic fingers? Discharge from eyes, ears or gum/mouth?(Required)

Yes

5. Do you Suffer From Recurring skin or ear trouble? A recurring gastrointestinal disorder?(Required)

Yes

6. Are you suffering from any other medical condition that could affect your ability to work, including working safely with food eg. Hepatitis?(Required)

Yes

7. Do you suffer with allergies?(Required)

Yes

8. Do you suffer from any other health problem that may affect your safety or your ability to carry out any work activities? Examples may include: Recurring back problem or your ability to lift/manually handle objects? Seizures/epilepsy; Diabetes.(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)