"Atos Origin Form � DWP"
HEALTH DECLARATION PLEASE BRING A SIGNED COPY OF THIS FORM WITH YOU TO THE NEXT STAGE OF THE SELECTION EXERCISE We need to ask you about your health and your record of taking sick leave with previous employers. Please answer the questions in Part 1 of this form. You will need to save this form on your computer before you start filling it in. Why we need to ask about your health and sick leave record. The Department for Work and Pensions is an equal opportunities employer and recruits on the basis of ability, not perceived disability. The reasons we need to ask about your health are: 1. If you have a disability or health condition, we need to understand how it could affect your ability to carry out the tasks of the job you are applying for. 2. It enables us to consider adjustments we could make to help you take up employment or carry out your tasks efficiently. 3. We must be confident that your attendance record will be good. If you have a disability or other health condition, we will consult the company that provides us with professional occupational health advice about workplace adjustments we might consider making. If you have a history of ill-health, we will seek advice about whether you are fit enough to work for us. We never decline to offer employment on health grounds without seeking advice from an occupational health professional. Your Consent. Depending on the information you provide, our occupational health advisers, Atos Healthcare, may need to speak to you or consult your GP before giving us advice. They will do this to ensure that the advice they provide is based on all the facts. By completing Part 2 of this form you will provide consent for Atos Healthcare to contact you, or your GP, if they need to. Confidentiality The information you provide on this form will be treated in the strictest confidence and will be seen by one of our Personnel Managers only if you are recommended for appointment. If you want the details of a health condition to be known only by a medical professional, you may give this form back to us in a sealed envelope. We will pass this on to Atos Healthcare unopened. Failure to Provide Information Your employment could be terminated if it subsequently comes to light that the information you provided was inaccurate or incomplete. HEALTH DECLARATION – PART 1 Your Name: Your date of birth: Details of the post applied for: Question 1: Do you have a disability? Please answer yes or no. If yes, please explain. Your answer: Question 2: Do you have any other health condition? Please answer yes or no. If yes, please explain. Your answer: Question 3: Are you on a waiting list to see a specialist as an outpatient, or have you seen one in the last six months? Please answer yes or no. If yes, please explain. Your answer: Question 4: Are you on a waiting list for an operation? Please answer yes or no. If yes, please explain. Your answer: Question 5: Have you ever had a medical condition that was or may have been caused by work factors? Please answer yes or no. If yes, please explain what the condition was and say whether you are in receipt of Industrial Injuries Benefit. Your answer: Question 6: Do you have difficulty with any of the following that interfere substantially with normal day to day activities? Tick the box if you agree Walking or mobility Vision (apart from needing glasses or contact lenses for correction) Ability to learn or understand things Ability to read Hearing Speech Ability to lift, carry or move everyday objects Memory Concentration Physical co-ordination Continence Manual dexterity Perception of risk or physical danger Question 7: Do you have any need for specific arrangements to assist in the performance of any aspects of your job? Please explain what these arrangements are. If any of your previous employers adjusted your working environment or terms of employment to assist you in relation to a disability or health condition, please tell us about it. Your answer: Question 8: Have you ever been refused employment on health grounds? Please answer yes or no. If yes, please explain. Your answer: Question 9: Have you ever left, been dismissed or retired from employment for health reasons? Please answer yes or no. If yes, please explain. Your answer: Question 10: How many days absence from work did you have off in the last 12 months with your most recent employer(s)? What was this for? Please provide the number of days and an explanation. Your answer: Question 11: Are you aware of any medical problems that may affect your ability to work regularly or effectively that you have not already told us about? Please answer yes or no. If yes, please explain. Your answer: Question 12: Our occupational health advisers will contact you if they need to talk to you face to face or by telephone about your answers. Please tell us if you need them to make special arrangements for this (e.g. if you have mobility problems). Your answer: Signed Date Print Name HEALTH DECLARATION – PART 2 Atos Healthcare Consent Form We need to ask our Occupational Health providers Atos Healthcare to provide advice regarding your current health / wellbeing in relation to your employment. To do this we require your informed consent. Please complete each section of this form. Thank you. Personal Details – Please complete all details Surname: Forename (s): Title: Date of Birth Home Address Town: County: Post code: Contact Please give your direct line for work, not call centre Telephone or central numbers Numbers Please indicate, by ticking the Home: appropriate box, which number Direct Line for you can be contacted on between Current Work: the hours of 09:00 and 17:00 Mobile: Consent Declaration By completing the declaration I confirm that I consent to the DWP releasing to its Occupational Health Service Provider Atos Healthcare and Agents, personal data relating to my health, including but not limited to my absence record, medical/doctors certificates etc. and that Atos Healthcare may contact me in writing or by telephone to discuss and review my situation and that Atos Healthcare may provide a report advising the DWP about my health relating to work including, whether in their opinion I suffer from any underlying medical condition(s) and/or a disability for the purposes of the Disability Discrimination Act 1995. The report may also give advice on any reasonable adjustments that may be made. Please put a check in the boxes next to the statements you agree with. I agree to a referral to Atos Healthcare: I agree to be contacted by telephone on home/work/mobile number I have provided, to schedule an appointment: I agree to attend an appointment with a practitioner, if required: I agree to be contacted by telephone on home/work/mobile number I have provided, to participate in a telephone consultation, if required: I understand that my referral will be dealt with in medical confidence and that any advice given to my employer will be expressed in terms of my fitness for employment / or my fitness to carry out the duties of my role both now and in the future. I agree to my General Practitioner, and if necessary the Specialist I am attending, giving information about my medical condition, if requested by Atos Healthcare. (In respect of requests for further medical evidence questions will only be asked that relate to the reason the consent was provided). Access to Medical Reports Act 1988 Under the terms of the above act you have the right to withhold your consent to OHCSS to apply to your general practitioner / hospital specialist for medical information. If you give your consent you have the right to see the information in the report before it is sent to OHCSS. You have 21 days from the date of the OHCSS letter notifying you that a report has been requested, in which to ask your general practitioner / hospital specialist to let you see the report. They will tell you if you cannot see any part of the report for professional medical reasons. If you are given access to the report your General Practitioner / Specialist will not send it to OHCSS until you give your consent. If you regard any information in the report as incorrect or misleading you can ask, in writing, for it to be amended. (Please note, if your General Practitioner or Specialist does not accept that the information is incorrect or misleading, they are not required to make any amendment, but in these cases they will invite you to prepare a written statement on the disputed information, which will be attached to the report when it is sent to OHCSS). Subject to the provision of the Act, you have the right to see information about your medical condition for up to six months after it has been sent to OHCSS. If your General Practitioner /Specialist gives you a copy of the report, they may charge you a reasonable fee to cover the cost of supplying it. I wish to see any such report before it is sent to Atos Healthcare. I agree that relevant medical notes can be submitted, in confidence, to the agents for the Civil Service Pension Scheme (CSPS). Data Protection Act 1998 Access to Medical Reports Act 1988 does not affect an individual’s right to make an access request in relation to their personal data in accordance with the DPA 1998. General Practitioner’s Details Surname: Title: Initials Address: Town: County: Post Code: Telephone: Other Specialist's Details, if applicable Surname: Title: Initials Speciality: Address: Town: County: Post Code: Hospital Unit No. Telephone: Signed: Date: