Application to Register as a Casual Teacher - Education and ...

Health QuestionnaireTo be completed by all applicants for employmentwith the Education and Training DirectorateThe purpose of this questionnaire is to ascertain that applicants are fit to undertake the duties of theposition/s for which they are applying. Applicants should be aware that the Directorate may request anexamination by a medical adviser nominated by the Directorate on the basis of information provided inthis questionnaire.1. Angina, heart disease, persistent chest pain, heart operation?2. High or low blood pressure, frequent palpitations?Please Tick: Yes No3. Pain or disability in the lower back or neck?4. Pain or limitation on use of the upper limbs?5. Pain or limitation on use of the lower limbs?6. Occupational Overuse Syndrome or Repetitive Strain Injury?7. Anxiety state, stress, difficulty with concentration or memory?8. Depression or difficulty in sleeping?9. Excessive fatigue/unusual weakness or tiredness?10. Do you have a current work related injury or illness?Are you aware of any medical condition or other factor relating to your health and physicalfitness which may prevent you from performing the duties of the position/s for which youare applying?If yes, please state:I declare that I have supplied all information required and have not provided any false information.Signed: ______________________________________________________ Date: ____ / ____ / ________Name: ____________________________________________________________________ (Please Print)This form requests information about you, which will be held securely by the Directorate. Theinformation is collected as a lawful administrative function of the Education and Training Directorate andwill be used for employment matters.Page | 4