The Employee Health Declaration Form Template UK is available in multiple formats, including PDF, Word, and Google Docs, featuring customizable and printable examples.
Employee Health Declaration Form Template UK Editable – PrintableSample
Employee Health Declaration Form Template UK 1. Employee Information 2. Emergency Contact Information 3. Medical History 4. Current Medications 5. Health Conditions 6. Occupational Health Assessment 7. Work Environment Considerations 8. Social History 9. Declaration of Accuracy 10. Consent for Medical Examination 11. Signature and Date
PDF
WORD
Examples
[Full Name]
[Date of Birth]
[Employee ID]
[Department]
[Position]
[Home Address]
[Phone Number]
[Email Address]
I, [Full Name], hereby declare that the information provided in this health declaration form is, to the best of my knowledge, accurate and complete. I understand that providing false information may result in disciplinary action.
1. Do you have any pre-existing health conditions? [Yes/No]
If yes, please specify: [List conditions]
2. Have you had any recent illnesses or injuries? [Yes/No]
If yes, please specify: [List illnesses/injuries]
3. Are you currently taking any medication? [Yes/No]
If yes, please list: [List medications]
Please indicate your vaccination status for the following:
– COVID-19: [Vaccinated/Not Vaccinated]
– Flu: [Vaccinated/Not Vaccinated]
– Other vaccinations: [Specify any other vaccinations]
If you answered ‘yes’ to any health questions, please detail if there are any specific considerations or accommodations you require for your return to work: [Specify details]
[Signature of Employee]
[Full Name]
[Full Name]
[Job Title]
[Department]
[Employee Number]
[Contact Name]
[Relationship]
[Contact Number]
I confirm that the below statements regarding my health are true:
1. Have you ever been diagnosed with a chronic illness? [Yes/No]
If yes, please specify: [Details]
2. Do you have any allergies? [Yes/No]
If yes, please specify: [Details]
3. Is there any other relevant health information that the employer should be aware of? [Yes/No]
If yes, please specify: [Details]
Do you consider yourself fit to perform your job duties? [Yes/No]
If no, please explain: [Details]
In case of emergency, may we contact your healthcare provider? [Yes/No]
If yes, please provide their details: [Name, Phone Number, Address]
I declare that the above information is true and accurate to the best of my knowledge. I understand that misrepresentation may lead to disciplinary action.
Signed in [City], [Date].
[Signature of Employee]
[Full Name]
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