Pre-Employment Fitness to Work & Medical Health Declaration (HR-F021) FITNESS TO WORK / MEDICAL HEALTH DECLARATION (HR-F021) Contact FITNESS TO WORK / MEDICAL HEALTH DECLARATION Pre-Employment Fitness to Work & Medical Health Declaration (HR-F021)SECTION 1: EMPLOYEE BASELINE DATA & LEGAL NOTICETitle- Select -MrMrsMissMsMxOtherStaff Member NameStaff_IDJob TitleCare Worker / Support WorkerComplex Care WorkerSenior Care Worker / MentorField SupervisorCare Coordinator / Rota SchedulerClinical LeadQuality Assurance / Compliance OfficerHR / Recruitment AdministratorImplementation ResearcherDeputy Care ManagerRegistered Care ManagerOperating Local Authority- Select -HaringeyIslingtonBarnetWaltham ForestCamdenHackneyBrentHarrowRedbridgeNewhamCity of LondonWestminsterTower HamletsBarking and DagenhamHaveringKensington and ChelseaHammersmith and FulhamEalingHillingdonHounslowSouthwarkLambethLewishamGreenwichWandsworthRichmond upon ThamesMertonKingston upon ThamesSuttonBexleyBromleyCroydonOtherLegal Declaration- Select -I understand this form has been issued following a conditional offer. Its purpose is not to screen me out, but to proactively identify any Reasonable Adjustments required to ensure my safety and the safety of service users.SECTION 2: PHYSICAL DEMANDS, LONE WORKING & ENVIRONMENTAL RISKS (Safe QS5 & QS6)Moving and Handling: Do you have any current or historic musculoskeletal conditions (e.g., back pain, slipped discs, joint issues, repetitive strain) that could be aggravated by operating hoists, stand-aids, or prolonged standing?- Select -YesNoN/ACurrent or historic musculoskeletal conditions- Select -Condition fully managed; no operational restrictions required.Light duties onlyMechanical restrictionMobility restrictionRequires formal ergonomic assessment prior to commencement.Environmental & PPE Allergies: Do you suffer from severe allergies to domestic pets (cats/dogs), latex, or have severe skin conditions (e.g., contact dermatitis) that could be aggravated by required PPE or constant IPC hand-washing?- Select -YesNoN/APregnancy: Are you currently pregnant, or have you given birth within the last 6 months?- Select -YesNoN/APrefer not to sayCurrently pregnant, or have given birth within the last 6 months- Select -Mandatory 'New and Expectant Mothers Risk Assessment' triggeredDriving & Vision (If applicable): Do you suffer from any medical condition (e.g., epilepsy, severe visual impairment, sleep apnoea) that affects your legal entitlement to drive, or that must be reported to the DVLA?- Select -YesNoN/ASECTION 3: STATUTORY NIGHT WORKER HEALTH ASSESSMENT (Working Time Regulations 1998) & COGNITIVE WELLBEING (Caring QS5)Night Work Opt-In: Will your role involve working at least 3 hours between 23:00 and 06:00?- Select -YesNoN/AStatutory Assessment: Do you have any medical condition (e.g., diabetes, cardiovascular disease, gastrointestinal issues) that may be adversely affected by working night shifts?- Select -YesNoN/APsychological Wellbeing: Do you have any current or historic mental health conditions (e.g., severe depression, anxiety, PTSD) that might be aggravated by lone working or high-stress emergency situations?- Select -YesNoN/ACognitive / Neurodivergence: Do you have any learning disabilities, neurological conditions, or neurodivergent traits (e.g., Dyslexia, ADHD, Autism) that may affect your ability to read medication labels accurately or complete digital care notes?- Select -YesNoN/AWhat specific support, adjusted training formats, or supervision frequency would help you safely manage these demands?- Select -No specific workplace support or adjustments required at this time.Adjusted training formats (e.g., extra processing time, dyslexia-friendly fonts, colored overlays).Enhanced pastoral support (e.g., more frequent 1Scheduling limits (e.g., avoidance of complex/high-stress end-of-life packages during initial probation).Formal Occupational Health / 'Access to Work' assessment requested.SECTION 4: GENERAL HEALTH & INFECTION CONTROL (Safe QS7), REASONABLE ADJUSTMENTS (Effective QS2) & CONSENTImmunisation Status (Check all that apply and are up to date)COVID-19Seasonal Influenza (Flu)Hepatitis B (Recommended for roles involving delegated healthcare tasks)Tuberculosis (BCG)Measles, Mumps, Rubella (MMR)Varicella (Chickenpox)Sudden Incapacitation: Do you suffer from any condition that could cause sudden loss of consciousness or severe dizziness (e.g., severe Type 1 Diabetes, severe Epilepsy)?- Select -YesNoNAImmunocompromised Status: Do you have any medical condition, or take medication, that makes you highly vulnerable to transmissible infectious diseases?- Select -YesNoNAPlease explicitly detail any 'Reasonable Adjustments' you believe Mutima Care needs to implement under the Equality Act 2010 to enable you to perform your role safely- Select -NoneEnvironmentalSchedulingTechnological/SensoryPhysical/ErgonomicComplex/Multiple NeedsOH Referral Consent- Select -I consent to Mutima Care referring my case to an independent Occupational Health (OH) professional if further workplace assessment is required.Access to Medical Reports Act 1988 (AMRA) Consent- Select -Should OH or Mutima Care require a medical report directly from my own GP or clinical specialist, I understand that my explicit consent under AMRA will be sought via a separate statutory form.SECTION 5: FINAL DECLARATIONS & AUTHORISATIONEmployee Declaration- Select -I declare that the answers given are true and complete. I understand that failing to disclose a material health condition that subsequently places a vulnerable adult or myself at risk may result in the withdrawal of the employment offer or disciplinary action.Assessment Outcome- Select -Cleared for Work - No adjustments required.Cleared for Work - Internal Reasonable Adjustments agreed and integrated.Pending - Formal OH Referral required.Not Fit for Work - Offer withdrawn on medical grounds (HR/Legal consultation required).Registered Manager Authorisation- Select -I confirm this health declaration is reviewed. Necessary rota constraints, IPC blocks, or reasonable adjustments are now locked into the rostering softwareDateNext Review Date:SUBMIT FORM
