Medical Examination Consent Form

{{company_name}}

{{company_address}}

Phone: {{phone}} | Email: {{email}} | Web: {{website}}

Medical Examination Consent Form

Complete all sections of this medical examination consent form in BLOCK CAPITALS. Incomplete forms cannot be processed.

Employee Details

Request / Information

Declaration

I confirm that the information provided in this form is true, complete, and accurate to the best of my knowledge. I understand that providing false information may result in disciplinary action.

Manager Review

HR Action

Acknowledgement & Signatures

By signing below, both parties confirm they have read, understood, and agreed to the terms of this document.

Scope

Applies to all employees, contractors, and visitors of {{company_name}} while at Company premises or engaged in Company business.

Definitions

• "Occupational Health" means health risks arising from or related to work.
• "Reasonable Accommodation" means any modification to enable performance of essential duties.
• "Health Information" means medical, fitness-for-work, and related personal data.

Roles & Responsibilities

Risk Categories & Controls

Fitness for Work & Accommodations

1. Employees with a medical condition affecting work shall notify HR in confidence.
2. An occupational health assessment may be arranged at Company cost where required.
3. Reasonable accommodations are agreed in writing with the employee and manager.
4. Confidential medical records are stored separately from personnel files.

Incident & Injury Reporting

Confidentiality of Health Data

Health information is processed only on a legitimate basis under applicable data protection law. Access is restricted to authorized health and HR personnel, and disclosure to managers is limited to fitness-for-work conclusions.

Document Control