New Starter Checklist

Clock Card Number*

Factory/Dept*

Section*

First name(s)*

Last name or family name*

Are you male or female?*

Date of birth dd/mm/yyyy

Address*

Town*

Postcode*

Home telephone Number*

Mobile telephone number

Email address*

National Insurance Number*

Employment start date dd/mm/yyyy*

Bank name*

Name of account holder*

Sort code*

Account number*

Rate of pay p/h*

Please select only one of the following statements*

This is my first job since last 6 April and I have not been receiving taxable Jobseeker’s Allowance, Employment and Support Allowance, taxable Incapacity Benefit, State or Occupational Pension. This is now my only job but since last 6 April I have had another job, or received taxable Jobseeker’s Allowance, Employment and Support Allowance or taxable Incapacity Benefit. I do not receive a State or Occupational Pension. As well as my new, I have another job or receive a State or Occupational Pension.

I have a Student Loan which is not fully repaid and I left a course of UK higher education before last 6 April and received my first Student Loan instalment on or after 1 September 1998. Select ‘No’ if you are repaying your Student Loan direct to the Student Loans Company by agreed monthly payments.

Student Loan*

Yes No N/A

Contact 1 Name*

Contact 1 Number*

Contact 1 Email Address

Contact 2 Name*

Contact 2 Number*

Contact 2 Email Address

Please answer the following questions.

Name of Doctor

Address

City

Postcode

Allergies*

Yes No

Asthma*

Yes No

Hay Fever*

Yes No

Chronic Cough*

Yes No

Pleurisy*

Yes No

Pneumonia*

Yes No

Sinusitis*

Yes No

Tuberculosis*

Yes No

Cardiovascular

Chest Pain*

Yes No

Heart Disorder*

Yes No

High Blood Pressure*

Yes No

Palpitations*

Yes No

Rheumatic Fever*

Yes No

Stroke*

Yes No

Digestive System

Hernia*

Yes No

Jaundice*

Yes No

Peptic Ulcer*

Yes No

Rectal Bleeding*

Yes No

Irritable Bowel Syndrome*

Yes No

Neurological

Dizzy Spells*

Yes No

Epilepsy*

Yes No

Fainting Attacks*

Yes No

Paralysis*

Yes No

Severe Headaches*

Yes No

Multiple Sclerosis*

Yes No

Genito-Urinary

Kidney Stones*

Yes No

Pain on Urination*

Yes No

Sugar/Albumin Urine*

Yes No

Kidney Disease*

Yes No

Musculoskeletal

Arthritis*

Yes No

Backache*

Yes No

Back Injury*

Yes No

Disc Disorder*

Yes No

Gout*

Yes No

Joint/Tendon Disorder*

Yes No

Rheumatism*

Yes No

Senses

Colour Blindness*

Yes No

Ear Disorder*

Yes No

Eye Disorder*

Yes No

Nose Disorder*

Yes No

Throat Disorder*

Yes No

Speech Disorder*

Yes No

Neurodiversity / Learning

Dyslexia*

Yes No

Dyspraxia*

Yes No

ADHD*

Yes No

Autism*

Yes No

Miscellaneous

Anaemia*

Yes No

Anxiety*

Yes No

Blood Disorder*

Yes No

Cancer*

Yes No

Depression*

Yes No

Diabetes*

Yes No

General Debility*

Yes No

Insomnia*

Yes No

Skin Disorder*

Yes No

Dermatitis*

Yes No

Autoimmune Condition*

Yes No

Thyroid Disorder*

Yes No

Any other medical conditions (not listed above), please provide details of any other medical conditions that may affect your work

Are you currently taking medication that may affect your work or safety?*

Yes No

Details

Work Capability

Do you have any difficulty with any of the following

Lifting*

Yes No

Standing long periods*

Yes No

Sitting long periods*

Yes No

Driving*

Yes No

Using display screen equipment*

Yes No

Working at height*

Yes No

Shift/night work*

Yes No

Disability (Equality Act 2010)

Do you consider yourself to have a disability*

Yes No Prefer not to say

If yes, please state any adjustments required

Declaration

I confirm that the information provided in this questionnaire is true, accurate and complete to the best of my knowledge.

I understand that I have a responsibility to disclose any medical condition that may affect my ability to work safely or may pose a risk to myself or others, where relevant to my role

I acknowledge that knowingly providing false or misleading information, or deliberately withholding relevant information, may result in action being taken in accordance with the organisation’s disciplinary procedures.

I understand that this information will be treated confidentially and processed in line with UK data protection legislation.

I confirm the above declaration

Full name*

Date dd/mm/yyyy*