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AECT_Medical Self Declaration Form. (1) (1)

The Medical Self Declaration Form is designed to ensure the health and safety of employees by collecting information about their medical conditions. Employees must disclose any significant health issues, disabilities, or medications that may affect their job performance, while minor illnesses do not need to be reported. The information provided will remain confidential and is necessary for workplace safety and compliance with health regulations.

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8 views

AECT_Medical Self Declaration Form. (1) (1)

The Medical Self Declaration Form is designed to ensure the health and safety of employees by collecting information about their medical conditions. Employees must disclose any significant health issues, disabilities, or medications that may affect their job performance, while minor illnesses do not need to be reported. The information provided will remain confidential and is necessary for workplace safety and compliance with health regulations.

Uploaded by

srinivasa reddy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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ARKA EDUCATIONAL AND CULTURAL TRUST

MEDICAL SELF DECLARATION FORM

The form has been created to meet mutual responsibilities in taking reasonable care to protect the health and safety of
yourself and others in the workplace. The intent of this form is to provide necessary support and help us understand any
medical conditions that may affect your health. You do not have to tell us about any minor illnesses that you have not needed
medical treatment for, such as flu.

Please ensure that you fill and complete all components of the Declaration, including providing additional, supporting
information and documentation where indicated.

Have you had or do you suffer from any of the following Yes No
Unconsciousness for any reason / Dizziness or fainting spells
Ailment related to brain/nervous system/stroke/paralysis/epilepsy
Blood Pressure (High / Low) / Anaemia or other blood related chronic disorder including
abnormal bleeding
Heart Troubles: Chest pain/ palpitation or any heart related disorder / Abnormal Cardiac
Rhythms
Diabetes (Insulin dependent or any form of controlled diabetes) / Chronic disease related
to Kidneys or Urinary System
Anomaly related to liver / reproductive system
Do you have unclear speech or hesitation when you speak?
Do you have trouble in hearing a whispered voice or a watch ticking? (Hearing aids are
acceptable)
Do you have hernia that has not been correct satisfactorily by a curative operation?
Have you been affected by pulmonary tuberculosis?
Have you been affected by or treated for Gastrointestinal disorder?
Have you ever been treated for any cancer / tumour / cyst or other growth?
Have you undergone any operation(s) involving Eyes, Brain, Heart, Nerves, Blood
Vessels, or Bones
Eye Trouble (Except Glasses)
Allergies (including allergies due to medical drugs)
Admission in hospital in last 12 months
Any Psychological / Emotional / Mental stress issues?
Are you undergoing treatment for any of other medical condition(s) that is not mentioned
above?
Sl.No Details
1

a) Do you currently have any disability (including learning disability) or medical condition and/or restrictions which
might prevent or impede you from being able to satisfactorily perform any duties that might be required of you in
the role for which you have been appointed? This information will not be used to discriminate in any way, and we
also assure that this information shall remain confidential.
If yes or unsure, please provide details: (Please include details of any assistance/ adjustments that
would allow you to carry out the functions of the role.)
………………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………….

Please Note: If you have any disability or medical condition which might require workplace modifications to either assist
to ensure your health and safety in the workplace or to enable you to satisfactorily perform the duties of the role for which
you have applied, you are required to provide detail. This information is necessary to enable management to meet its
obligations under health and safety legislation and, where relevant, to ensure appropriate modifications or assistance to
provide a safe system of work for you in the event you are offered employment. The provision of any such information will
not be used to discriminate against you because of the existence of any such disability or medical condition.

b) Are you taking or consuming any prescription medication/s or other substance/s that may affect your ability to
perform the duties of the role you have been appointed for or affect mental capacity to discern right and wrong or
give rise to a risk to your health or safety in the workplace or that of other employees? If yes, please provide details:

………………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………….

c) Do you agree to undergo a medical examination that relates to your capacity to perform the functions of the role
you have been appointed for if the management deems fit? If no, please provide details:

………………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………….
I (Name of the Employee) …………………………………………………………………………….
Confirm that to the best of my knowledge, the answers given above are true and correct and I can perform all my routine
activities independently. I also confirm that I have read and understood the form and that failure to disclose any relevant
information may result in disciplinary action which may even extend to suspension/termination.

I understand that any information provided in this Declaration may be checked by the relevant authorities or sources.

Signature of the Employee________________________ Date: __________________

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