Do you take insulin or medication? YesNo
Details:
If YES to above - Are you taking ANY medication?
If YES, give year?
If YES, Did you wear hearing protection? YesNo
How many per day?
If yes, how much do you drink per week?
If yes, what drugs? When did you last take drugs (what and when)?
Rorcon has a Zero tolerance Drug & Alcohol policy for anyone in our workplaces & those managed by our clients. Many of our Clients operate Random Drug & Alcohol Testing. This means that you may be asked to undertake a test at any time at work - Refusal to cooperate with a testing request will result in your immediate suspension from the workplace until you are tested. If you should fail an initial test, you will be asked to leave site & be suspended pending the outcome of a follow up test.
Once the results of a second test are available, should the follow up test be positive (i.e. showing the presence of drugs and/or alcohol), as a minimum, you may receive a written warning & guidance based on the results, but the more likely scenario is that you will be immediately dismissed from our employment for a “serious breach of your employment contract”.
I declare that the information given on this form is true and to the best of my knowledge. I further declare that I have not omitted or falsified any facts or details that could have a bearing on my state of health
I will notify my Manager if I develop any of the above conditions in the future. I declare that I have been advised regarding the purpose of this health assessment, and agree to take part.
If you have an accident at work, however, minor you may consider it, you must record it in the accident book or sheet immediately. You must provide details of the nature of the accident or injury, any first aid treatment that was administered, the names of any witnesses and the date and time and place of the accident.
In signing this form, you confirm your explicit consent within the meaning of GDPR (General Data Protection Regulation) for Rorcon to process and store your personal information. If at any time you wish to have access to your Medical Questionnaire you may do so by requesting this in writing.
