Passion Home Care | Health Questionnaire

Which position are you applying for?*

Job Reference Number if Applicable

Closing Date for the Position

Data Protection Consent Statement

In submitting the information via the website you are agreeing to us holding your information for the purpose of applying for a job at Passion Home Care or are requesting your details to be held on file should a suitable position become available. Data submitted via the website will be held for 12 - 24 months in our email accounts and on our back office systems. Data held on the website will be deleted within 12-months. If you require more information on our Data Protection Policy and Data Retention Policy prior to submitting any details please use the contact form. If you do not want us to hold your information on our systems please telephone us to discuss.

Data Protection Consent*

Yes - You agree to the data submitted via the form kept on our systems for up to 24-months.

No - Please delete it immediately.

PERSONAL DETAILS AND CONTACT

The following section should be completed. All fields are mandatory.

Name*

Address*

Email*

HEALTH QUESTIONNAIRE

Please complete the following form.

Initial Questions

Regulation 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 states that a person employed for the purposes of carrying on a regulated activity must be physically and mentally fit for that work. Please answer the following questions:

How many days were you absent from work due to sickness in the last year? *

Have you ever suffered from: Allergies, eczema, dermatitis or other skin troubles?*

Do you suffer from: Epilepsy, migraine, asthma, angina, heart trouble or any condition requiring long-term medical help or a strict medication timetable? *

Have you ever suffered from: Mental illness including anxiety, depression or nervous debility?*

Have you ever required treatment for: Hernia or rupture, rheumatism, back problems, slipped disc, sciatica or Repetitive Strain Injury (RSI)?*

Do you suffer from: Diabetes, ulcers, stomach or other intestinal disorders?*

If you have answered yes to any of the questions above, please provide further details below.

Health Declaration

I hereby confirm that I know of no reason, in relation to either my physical or mental health, why I would be unable to undertake the duties required for the post applied for.

Health Declaration*

Date*

Electronic Signature Confirmation

I can confirm that to the best of my knowledge the above information is correct. I accept that providing deliberately false information could result in my dismissal.

Electronic Signature*

Date of Electronic Signature*

Data Consent

In ticking the following box and submitting the data completed in the above form you agree to us processing the information as stated at the start of the form. You will need to tick the box prior to submission.

Data Consent*

Data Consent

Instructions

When submitting this form it will generate an email to Passion Home Care. The information completed is the third part of the application process and on the successful submission you will be redirected to the ID Verification Form. When completing this form please use the same email address as used as part of this submission. We will not process an application until we have received the "Job Application", "Health Questionnaire", "Equal Opportunities", "ID Verification Form" and the "Rehabilitation of Offenders Declaration".

Disclaimer

Passion Home Care will not accept a partially complete application and if any of the forms are missing we can not guarantee your application will be considered. For each form you will receive a confirmation email confirming the submission and we recommend that you retain this as proof. On submission you will be redirected to the next form but you do not need to complete within a specified time as long as all are received prior to the closing data of the advertised position.