Thomas Cook - Decrease in Medical Fitness - Unable to work for health reasons
This questionnaire must only be completed if you plan on returning to work within the next seven days.
The information provided in this questionnaire will be treated confidentially and will not be passed on to your employer. The employer will only be advised of the outcome of the assessment in terms of ‘fit’ or ‘not fit’.
Please note that incorrect or incomplete forms will not be processed and you will be asked to resubmit the questionnaire.
What was the reason for your inability to work?
If you answered yes, please providce details.
Please provide the date and type of the operation and of details regarding any planned follow-up.
If you answered yes, please provide details.
Please provide details regarding type of treatment, any medication you have been prescribed or any advice you have been given.
If you answsered yes, please provide details
please provide name and dosage of the medication and specify whether you are suffering with any side effects.
If you answsered yes, please provide details.
Please provide details and specify whether these are having a negative impact on your ability to carry out normal daily activities.
I hereby declare that I have carefully considered the statements made here and that to the best of my knowledge they are complete and correct and that I have not withheld any relevant information or made any misleading statement