Applicant's Medical Declaration S

Applicant's Medical Declaration

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Have you ever had, or do you presently have, any of the following? YES NO 1 Fits, blackouts, epilepsy, fainting attacks, head injuries, severe frequent or prolonged headaches or migraines?
2 Chest problems including asthma, bronchitis, emphysema, pleurisy, unexplained breathlessness, Tuberculosis, persistent cough or hay fever?
3 Heart disease, Angina, or High Blood Pressure?

4 Eye Disease, or defect of vision including colour?

5 Ear conditions, e.g. discharge, infections, hearing difficulties, deafness or loss of balance? 6 Back pain, neck joint pain or restriction of movement?
7 Arthritis, rheumatoid arthritis, slipped discs, arthralgia?

8 Liver/kidney or bladder disease, including jaundice?

9 Skin conditions, including eczema, dermatitis, psoriasis? (Do not include acne) 10 Allergies to any substances including medication or vaccinations/immunizations?
11 Gastric or duodenal ulcers, frequent or prolonged indigestion, persistent diarrhea, salmonella, gastroenteritis, typhoid dysentery? 12 Operations?
13 Diabetes (if yes age of onset and treatment)?
14 Any illness or injury requiring treatment or investigation by a doctor, hospital or other therapist? 15 Are you currently receiving treatment, medication or counselling?
16 Do you have any disability which may require adjustment to your working environment? 17 Have you ever been retired from work on the grounds of ill health?
18 Do you have any Smoking Related illness?
19 Do you have any Alcohol or Drug related illness or dependence?
20 Is there any additional information that Concordia should be aware of?





If you have answered 'yes' to any of the above questions please give details here (including dates for operations):

Please indicate COVID status vaccination here:

1. Please indicate SINGLE, DOUBLE or NO vaccination _________________________________________________ 2. Please give details of name of the vaccination _______________________________________________
3. Do you have certificate of vaccination in English? ___YES/NO________________________

How many days have you lost from work, school, university or college in the last two years due to illness or injury? *_____

Please provide the name and contact details of your GP: ___________________________________________________

Please provide the date of your last tetanus vaccination: ___________

PLEASE READ THE FOLLOWING POINTS CAREFULLY BEFORE SUBMITTING YOUR ANSWERS:
I give my consent to be medically examined by my employer's or Concordia's Occupational Health Adviser, if necessary.
(Female Employees) I understand that I must notify my Employer if I become pregnant at least 15 weeks before the week that the baby is due.

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I will provide a blood or urine sample if requested to do so by my Employer's or Concordia's Occupational Health Adviser, in connection with the
implementation of the Employer's Alcohol and Drug Policy.
I certify that the answers to the above questions are correct.

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I understand that any false or misleading information including the concealment of a material fact, will lead to the termination of my contract of
employment.

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I certify that I am presently in a good physical condition and mental health condition and I am physically fit to work as a Seasonal Harvest /
Production participant.
I understand that it is my responsibility to update Concordia if any information I have given here changes before I begin my employment.I understand that relevant information given in this declaration may be shared with my employer.

Applicant’s Name Surname Signature (підпис) Date

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