Full Name

Email Address

Health and Fitness Questionnaire

Please answer the following questions

1> Do you have, or have you ever had, any significant health problem, impairment / disability (physical or mental) or learning difficulties that may affect your ability to undertake the tasks set out in the job description of the post offered?
YesNo
2> Do you have, or have you ever had, any illness, impairment or disability that may have been caused or made worse by your work?
YesNo
3> Have you ever left or been denied employment in an organisation on the grounds of ill health or been medically retired on the grounds of ill health?
YesNo
4> Are you having, or waiting for, any medical treatment or investigations at present?
YesNo
5> Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?
YesNo

If you answered 'yes' to any of the above questions, please provide details below:

Immunisation status (Please specify your immunisation status and any immunisation needs you have for the role - optional)

Applicants Declaration

1> I confirm that the information given above is complete and correct. I understand that any incomplete, untrue or misleading information given will entitle the employer to reject my application, withdraw any offer of employment, or, if I am employed, dismiss me without notice.
YesNo
2> By my signature, I give authority to the employer to contact my GP for further details regarding any of the potential health problems I have declared above.
YesNo
3> I agree that SANA CARE SERVICES LIMITED reserves the right to require me to undergo a medical examination to assess my suitability for work.
YesNo
4> I do not wish to complete the questionnaire, and I do not wish to have a free health assessment.
YesNo
5> Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?
YesNo

Print Full Name / Signature

Date

Role Evaluation Questionnaire

Name

Job Title

Department

Who do you report to? (Name & Job Title)

Who are you responsible for? (Name & Job Title)

What is the main purpose of your job in overall terms, i.e. what are you expected to do?

What are the key activities you have to carry out in your roles? (List them under no more than 10 points.)

What are the results you are expected to achieve in each of those key activities?

What are you expected to know to be able to carry out your job?

What skills should you have to carry out your job?

Mandatory Vaccination Supervision Log

Name

Role

1st Meeting Date

Supervisor

Do you intend to get your COVID – 19 / Flu vaccinations?
(Note: Health and Social Care workers working in CQC regulated settings must receive their first dose of the COVID-19 vaccine by the 3rd February 2022 to ensure they are fully vaccinated by the 1st April 2022)
YesNoExempt

COVID-19 / Flu Vaccination Status

1st Dose

2nd Dose

3rd Dose

COVID Booster

Exempt

Flu Vaccine Date (currently not mandatory)

Evidence seen by

Name

Date

If not, please give your reasons below

What support has been offered to support vaccination?

Supervision information session YesNoN/A
Time off for vaccination appointments YesNoN/A
Time off for GP appointments YesNoN/A
Referral to Occupation Health YesNoN/A
Self-referral for NHS mental health support YesNoN/A

If exempt, please give your reasons below

Medical information requested YesNoN/A
Medical evidence seen YesNoN/A
Risk assessment completed YesNoN/A
Additional PPE required YesNoN/A
Consider safeguarding YesNoN/A

If refusal, what actions were taken?

Government regulation explained and given in writing YesNoN/A
Dates given for compliance with regulation YesNoN/A
Suspension letter given YesNoN/A
Notice to comply with regulatory requirement given Alternatives YesNoN/A
to termination considered, including redeployment If YesNoN/A
redeployment is an alternative, has this been offered? YesNoN/A
If redeployment is an alternative, has this been accepted? YesNoN/A
Termination process commenced YesNoN/A
Employee resignation YesNoN/A
Employer notice given YesNoN/A
Exit Interview held YesNoN/A
Comments including alternatives to termination considered, dates, times, and document references if applicable:

Form Completion

Supervisee Name

Date

Supervisor Name

Date

Information Resources Given

Skills for Care Guidance YesNoN/A
ACAS Guidance YesNoN/A
CQC Guidance YesNoN/A
GOV Guidance YesNoN/A
HR handout YesNoN/A

Information Resources Given

Revised Staff Handbook

Received By

Date

Revised job description

Received By

Date

Revised amendment to contract

Received By

Date

Mandatory Vaccination Individual Action Plan