Please read and complete the questionnaire below :

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To ensure that you are medically suited for night-working and to safeguard the health of all employees, it is necessary for this Questionnaire to be completed.  The Questionnaire is CONFIDENTIAL and only the notification of your fitness for employment will be sent to Human Resources / Senior Management.

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If it is considered necessary, the Doctor may request that he discusses the contents of your questionnaire in more detail either by requesting a consultation in person or over the phone.

 

In certain circumstances, further information about any relevant medical conditions may be required from your doctor or other health professionals involved in your care.  If this is necessary, your written consent will be requested and the workings of the Access to Medical Records Act 1988 explained.

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Important: Please complete all sections fully and sign declaration, consent and authorisation sections before submitting the form to Rockingham Occupational Health Ltd.

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General Data Protection Regulation (GDPR) 2018 – You or your authorised representative may apply for access to your own occupational health records under the GDPR 2018 by applying in writing to Rockingham Occupational Health Limited.  For a brief summary of GDPR see the bottom of the consent form or for more detail see our Privacy Policy.

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The Access to Medical Reports Act 1988 – This Act does not apply in this situation, as the doctor who examines you is not responsible for your clinical care.  He is acting as an independent medical adviser to your current (or prospective) employer.  For more information on Access to Medical Records see the bottom of the consent form..

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This form is powered Cognito Forms to securely collect and manage your personal information in compliance with GDPR. You can learn more about how Cognito Forms protects your personal information in the Cognito Forms Privacy Policy.​​

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