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The information you provide is kept entirely confidential and is required to ensure the safety of you and others. Therefore, we require you to make full disclosure of any health-related issues you might have prior to commencing employment with us. Any points of uncertainty can be discussed further with your home manager or a director of Integra. Integra may require you to attend a meeting with a general practitioner prior to confirming your offer of employment or after commencing employment. NAME (forename and surname) If any of the following apply or have applied in the past to you, please check yes or no as appropriate. Circulatory problems, such as varicose veins, phlebitis, thrombosis  Yes  No Heart problems, such as angina, high blood pressure, heart attack  Yes  No Chest problems, such as asthma  Yes  No Diabetes  Yes  No Epilepsy or fainting attacks  Yes  No Skin disorders  Yes  No Stress-related illness  Yes  No Mental illness or depression  Yes  No Drug or alcohol-related problems  Yes  No Recent operation or fracture  Yes  No Any current medication  Yes  No Back trouble, joints, tendons, including wrist tendons  Yes  No Any injury giving rise to a claim for industrial injury, etc  Yes  No Any other significant health issue (eyes, hearing, allergies)  Yes  No Any other reason (not covered above) why you may need an amendment to working conditions to undertake your duties as described in the job description  Yes  No If you have answered yes to any of the questions above, please give details. Please use a continuation sheet if necessary. If you have been off work for more than a two week period in the last five years, please disclose the reason for this and the duration of the time off work for each such occasion I hereby declare that the above information is correct to the best of my knowledge. SIGNATURE DATE g!xX}LUe=/9!emi4*YXKPjA jeJ6jVX2>af3\sQ~sy{ so}}~OĘ#"i"C@3[T# 4 CIVSJldQpJtZN;C;뒉~3Ҙ21˄l`L^)A{ߒ9~5I$WgNdTM#BÒfc]xmнo{@/F"e}@8@.:KW+'ڵ?ISF.xebdt~F`yS}.]Fȥɗ8qۥq鲒{Τ&j%rOsrS#z!nyiJ806H̗='6WFryz_꥟k\;3T_yXPsfH=1Uv\B҂#0{U~=&48pȷC.?< gvdFx >؊ܒ SN8g3CB>`.K֠iU/~~<\ ^'v71{2cf@t68_1K9t9D+ R {C dM.Ȍ{#S v [ l2!352E lΓyڽf r9^ֱ]16 s= ؆v-~k!g;}3O),oGw G.oov»ג;Q]Lܽ?@~[6::&z_ށMcy_N7hU:껄y|?HxCnfx8 /֣b3^(|2-m~L!w h n_~@#js!|G nǼs2p%usmU>}GynhSFϩk6kGO˩'\Ϭ=z3$:ؘU*?5sc.dtٲx zc3W~slYG݃_yIwatb-0ȳ=x&NEc^$eޏ]MV;-v &mxbY)mK5Koc.dG;ǡFz}*g^y0?Sʉ~W~m+85('j (mh|5}!}]b %$m.@19ࡱ> Root Entry qaLNdqrvorsQblcu4szKeiub3mf2g8 qaL qaLCONTENTSprop2 # mX]0,Å :+0h08@T B prop2B prop3ddddddddddddddddddddddddddddddddddddddddDICT| dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddVyOOh0@(08 ddddddddddddddddOh+'0d0prop3 AuvsxjatP0udblw1Aaq5eubr5h8 qaL qaLCONTENTSpSummaryInformation( qaL qaLCONTENTS8@\ 1st user//////,/,/5//////////,/,/5/////,/,/5/,/,/5////,/,/5//,/,/5//,/,/5////,/,/5////,/,/5////,/,/5///,/,/5///////,/,/5///////