Agency Health and Wellbeing Form - Tops And Shoots Careers

Health and Wellbeing Form

Please complete and submit. Any issues please let us know at agency@topsandaspire.co.uk

Name

First Last

Setting(Required)

Position(Required)

NHS number

Today's Date

Health Conditions

Listed below are aspects of health which can make some work activities difficult. To enable the company to support you whilst working, we need you to identify any additional equipment or support that you may need in order to undertake your role, based on the information provided below. If you have a disability and/or medical condition that has been diagnosed by a medical professional then we need to be aware of this. Please tick if you have been diagnosed with any of the conditions mentioned below or have problems with any of the following:

If you have a disability and/or medical condition that has been diagnosed by a medical professional then we need to be aware of this. Please tick if you have been diagnosed with any of the conditions mentioned below or have problems with any of the following:

If you have a diagnoses, disability, or medical condition that is not listed above, please state it below:

When were you diagnosed with this condition?

If you have ticked any of the boxes above, please provide as much detail below regarding the medical condition, how this affects you and what treatment is currently being received:

Is there any equipment, additional resources or support that you may require to undertake your role?

How many days off have you had in the last 2 years?

In addition to what you have disclosed above, do you suffer with any health concerns that you may require support with? (This may be a health concern that has not been or does not require diagnosis?) i.e. you have problems with your hands, but have not been diagnosed with a related medical condition:

Are you on any medication which may affect work activities or require time off for hospital appointments?

If your role requires you to work nights are you fit and healthy to undertake this work and shifts?

Yes

Do you have any routine appointments booked over the next 6 months we need to be aware of?

Have you had any serious illnesses or injuries in the last five years?

Would you have any objections to fellow colleagues knowing about any disabilities,impairments or health concerns, enabling them to support you within the workplace?

Yes

Do you have any dietary requirements ? if yes, please give further details.

Mental Health

What do you do to stay healthy? (both physically and mentally)

What could your manager do to support you to stay mentally healthy at work?

Are there any work situations that can trigger poor mental health for you?

How could poor mental health impact on your work?

Are there any early warning signs that we might notice if you are experiencing poor mental health?

What could be put in place to minimise risks of poor mental health or help you to manage the impact?

Is there anything in your preferred individual work style or temperament that your manager should be aware of?

If we do notice early warning signs, what should we do to support you?

What steps can you take if you start to experience poor mental health? (both work and home)?

Is there anything else that you would like to add?

Nursery Colleagues ONLY

The children that you will work with may not be immunised against the following, therefore it is the company’s recommendation that you ensure that all your vaccinations are up to date.

Please tick to confirm vaccinations (not sure if you're vaccinated? You can ask your GP to find out what vaccinations you've received):

The children that you will work with may develop the following contagious illnesses, which could expose you to the risk of developing these illnesses. Please tick to confirm if you have previously developed any of the following contagious illnesses:

Chicken Pox

Measles

Mumps

Shingles

Scarlet Fever

Rubella

Whooping Cough

Tested positive for Covid-19

Personal Data + Data Protection

Please note - It is a requirement from Local boroughs/Authority, Ofsted and CQC that we share information about you in regards to your employment such as references, DBS, qualifications, continuous training and supervisions, or any matter in regards to your performance or conduct. Please click here to view our Data Protection policy

Signature(Required)

Date(Required)

Health and Wellbeing Form

Health Conditions

Mental Health

Nursery Colleagues ONLY

Personal Data + Data Protection

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