Health Declaration

Name *

First

Last

Under the Equality Act 2010 the definition of disability is if you have a physical or mental impairment that has a 'substantial' and 'long-term' adverse effect on your ability to carry out normal day-to-day activities. Do you consider yourself to have a disability? *

• Yes
• No

Are you having, or waiting for, treatment or investigation of any kind at present? * *

• Yes
• No

Have you ever left a previous employment through ill-health or a work related injury or condition? * *

• Yes
• No

Do you have any back, neck or joint problems causing difficulty with standing, walking, bending, lifting or stair climbing *

• Yes
• No

If you answered yes to any of the above questions please provide additional detail

Signature *

Clear Signature

Submit