Full name:
Address:
Date of birth:
National Insurance number:
Doctors name:
Doctors address:
Position applied for:
Height:
Weight:
Please answer all the following questions by indicating either Yes or No. If you answer yes to any question please give more information in the Remarks column.
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Yes/No |
Remarks/Date/Description |
| 1. Have you EVER had any of the following |
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| 1a. Diabetes |
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| 1b. Juandice/Hepatitus |
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| 1c. Tuberculosis (TB) |
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| 1d. Typhoid or paratyphoid fever or Enteric Fever |
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| 1e. Persistent Diarrhoea, Salmonella or other |
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| 1f. Fainting fit, Epileptic fits or Blackouts |
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| 1g. Chest problems, Bronchitis, Asthma, Pneumonia or Pleurisy |
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| 1h. Vision defect in either eye, the need to wear glasses or contact lenses |
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| 1i. Ear trouble, infections or deafness |
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| 1j. Skin complaints such as Dermatitus, Eczema, boils, ulcers or Psoriasis |
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| 1k. Tenosynovitis, Tendonitis, tennis or golfers elbow, frozen shoulder or any other upper limb disorder |
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| 1l. Whiplash injury |
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| 1m. Back trouble, Lumbago, Sciatica or suffered from a slipped disc |
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| 1n. Heart trouble, shortness of breath or angina |
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| 1o. Muscle sprains or strains, the dislocation, fracture or breakage of a bone |
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| 1p. Anxiety, depression or a nervous complaint |
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| 1q. Allergies such as Hay Fever |
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| 1r. Any physical disability |
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| 1s. Persistent headaches or migraines |
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| 1t. Varicose veins |
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Yes/No |
Remarks/Date/Description |
| 2. Have you ever been dismissed or had to give up another job for medical reasons |
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| 3. Have you been off work continuously for more than a month in the last 5 years for medical reasons? |
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| 4. Do you regularly take medicines or tablets? |
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5. Have you had any reason to visit any of the following in the last two years? (Please tick all that apply)
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Yes/No |
Remarks/Date/Description |
| 6. Have you ever had to wear any type of splint or support on your arms or legs? |
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| 7. Have you ever had an industrial illness or accident? |
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| 8. Have you had any Anti-Tetanus injections in the last ten years? |
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| 9. Have you travelled abroad in the last year? |
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| 9a. Which country have you visited? |
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| 10. Have you ever used handheld vibrating tools, machines or hand fed processes in your job? (IF YOU SELECT NO PLEASE MOVE TO THE STATEMENT SECTION, IF YOU SELECT YES PLEASE COMPLETE SECTIONS 10a - 10e) |
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| 10a. Do you have any numbness or tingling of the fingers lasting more than 20 minutes after using vibrating equipment? |
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| 10b. Do you have numbness or tingling of the fingers at any other time? |
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| 10c. Do you wake at night with pain, tingling or numbness in your hands or wrists? |
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| 10d. Have any of your fingers gone white on cold exposure |
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10e. Please list your occupational history
Have you travelled abroad within the last 14 days?
If yes, please list the countries you have travelled to below. Please also include any transit stop offs.
Have you been in close contact with someone who has been diagnosed with coronavirus?
Do you have any of the following symptoms?
Statement
I am willing to undergo a medical clearance and/or medical examination as required by Igloo. I declare that the information given on this form is correct to the best of my knowledge. I agree that Igloo may consult my own doctor, if necessary.
I agree that it is imperative that I must inform Igloo of any developments concerning my medical condition in the future.
Gefco UK – Site Visitor Health Survey
As part of our efforts to safeguard the wellbeing of our employees, their families and the sites they work in, there are some changes to the visitor management process for 3rd parties who wish to access any of our sites in the UK. Please contact your local GEFCO host before attending any site.
Where a visitor or driver has travelled to or from a Category 1 country/area (as defined by UK NHS) in the last 14 days a Category 2 country/area or are experiencing cold & flu like symptoms they will not be granted access to the work areas.
The NHS have set up a site https://111.nhs.uk/covid-19 that contains the up to date checks.
Please note
If the person is displaying symptoms the decontamination procedure must be followed.
PRIVACY STATEMENT
Your personal data will be processed to detect if you as a visitor to a GEFCO UK site or operation can potentially be a carrier of a specific virus or pandemic subject to a health crisis within the meaning of the NHS / WHO. This is required to ensure the traceability of visitors in the event of possible contamination.
We can only admit visitors to any site or operation under the management of GEFCO UK, Central Boulevard, Prologis Park CV6 4BX following successful completion of this form.
The data processing is based on the legitimate interest of GEFCO UK LTD to protect our employees from potential contamination and/or to inform you, as visitor, of a potential risk of contamination.
