HEALTH DECLARATION – Applicant for Employment “APPENDIX-D”

Please complete and return this Health Declaration as soon as possible. If you need more space please attach a separate sheet of paper.

The information you provide will be considered as part of our normal enquiries in connection with your application for employment. If you knowingly give false information or willfully suppress any material fact, you will be liable to summary dismissal.

Surname (Block Letters) .........................................………………………. NRIC …..........................................……

Other Names (in full) ................................................……………………… Age .............................................…….

Address .......................................................................……………………. Date of Birth ..............................……..

.......................................................................................…………………… Telephone No. ..............................………

......................................................................................…………………… Postcode ......................................………

2 Job for which you have applied. ………………………………………………………………………………………

3 Height (without shoes) (cm) Weight (in indoor clothes without shoes) (kg)

Yes or No (if appropriate give further details

4 (a) Have you ever left any employment on grounds of ill health or irregular attendance?

(b) Have you been refused any employment on medical grounds?(c) Has any insurance company declined to accept a proposal to insure your life, or imposed special conditions?

5. (a) Have you ever had:-fits, fainting attacks, blackouts or epilepsy?(b) mental ill-health, nervous breakdown, other nervous problems,

anxiety, depression, phobias or stress-related problems?(c) heart trouble, including rheumatic fever or high blood

pressure?(d) hay fever, asthma, allergies, bronchitis, tuberculosis or other

chest disease?(e) gastric or duodenal ulcer or other digestive or bowel disorder?(f) kidney disease or bladder trouble (including stone or gravel)?(g) arthritis, rheumatism or gout?(h) any back or joint trouble, including slipped (prolapsed) disc?(i) any neck, shoulder or upper limb problems?(j) any blood disease?(k) any skin disease?(l) diabetes?(m) eye problems/disease?(n) ear problems/disease?(o) hernia/rupture?(p) varicose veins?(q) treatment by radio therapy or chemotherapy?

Yes/No (if appropriate give further details)

6 (a) Is your eyesight satisfactory for all normal purposes including the use of display screen equipment?

(b) Do you wear glasses/contact lenses?

(c) Is your hearing in each ear good for all purposes including use of the telephone?

(d) Do you have any speech difficulties?

(e) Do you have any difficulty with physical mobility?

(f) Do you have a requirement for any special facilities or equipment?

7 Do you smoke? YES / NO If “Yes”, how many do you smoke daily? …………………………

8 Are you aware of having any other illness/disability not covered by this questionnaire? YES/NOIf yes please provide details:-

9 Have you ever had treatment in hospital or have you been attended to by a doctor (excluding influenza, common cold, common childhood diseases and minor ailments)? YES / NOIf the answer is YES please give the following particulars for each occasion:-

Nature of ailment(use a separate line for each)

Dates of beginning and end of illness (as near as you can give

them)

Approximate total duration of absence due

to this ailment(weeks/days)

10 Please give an account of any absences from work due to minor ailments during the last two years:-

Nature of ailment(use a separate line for each)

Approximate number of absences due to this ailment

Approximate total duration of absence due

to this ailment(weeks/days)

11 Are you presently under medical supervision or ill in any way? YES / NO

Please provide details ..............................................................................................................................

12 State any medication currently prescribed for your use ...........................................................................

13 I declare that all the statements made on this form are true and complete to the best of my knowledge and belief.

I understand that I may be required to undergo a medical examination prior to my employment and at any time during the course of my employment by my employer.

Note: Any false, misleading or incomplete information may result in the offer being withdrawn or in summary dismissal

Signature of Applicant ...................................................................... Date ...........................................

If you have any queries regarding the contents of this form you can get in touch with the Human Resources Department.