Personal Health assessment

Your personal

health assessment

Solute Service requests this information because we need to be sure we have considered all your health needs in relation to the duties you are required to perform, so we do not needlessly risk your health in duties you will perform as a cleaner.

You are solely responsible to inform solute service managers on this form page and other forms we require you to complete in the future and during the active duty of cleaning if you have any health problems or your health would be at risk in a duty.

By completing this form and submitting this form you agree to this statement and will adhere to it.

If you have any questions call 0800 677 1358 or email soluteservices@gmail.com

If you think that any questions/information in the 'Your Health Assessment Form' does not relate to you please type N/A.

Your Personal data will only be used by Solute Service Management and administrators.

Your health assessment form

Name:

Email:

Phone:

Home Address:

Head - do you have dizziness and issues wearing head protection, and have you had any head injures that would effect you preforming your cleaning duties:

Eyes - do you have blurred vision and do you have prescription glass . would any injury and or impairment affect your abilities toto wear googles and or preform your duties as a cleaner:

Body - do you currently have health problem that we need to consider when you are preforming your duties of cleaning, example ' cannot lift due to medically diagnosed health problems' please state and attach or email documental proof from you doctor. email soluteservices@gmail.com

Attach any medical document

Upload file

feet, legs, arms, and hands - do you have any of the following :

Pain

Weakness

Twitches

Please comment further about where on you body you suffer this

Do you understand that you inform us at solute service and manager if you need health support and or personalized PPE and or RPE

YES

DO NOT UNDERSTAND

Proof of Identity - we require this to confirm your the person completing this form

Upload file

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Your personal

health assessment

Solute Service requests this information because we need to be sure we have considered all your health needs in relation to the duties you are required to perform, so we do not needlessly risk your health in duties you will perform as a cleaner.

You are solely responsible to inform solute service managers on this form page and other forms we require you to complete in the future and during the active duty of cleaning if you have any health problems or your health would be at risk in a duty.

By completing this form and submitting this form you agree to this statement and will adhere to it.

If you have any questions call 0800 677 1358 or email soluteservices@gmail.com

If you think that any questions/information in the 'Your Health Assessment Form' does not relate to you please type N/A.

Your Personal data will only be used by Solute Service Management and administrators.

Your health assessment form

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