Thomas Cook – Renewal

Thomas Cook – Appendix B Cabin Crew Periodic Assessment In Accordance With Part-MED MED.C.005

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.


Title
First Name
Surname
Previous Name
Date of Birth
Staff Number
Gender
Email Address
Telephone number
Place of birth
This MUST be as shown on your passport.
Address

Nationality
This MUST be as shown on your passport.
Question 1.

Are you currently on sick leave or maternity leave?

Details

If you answered Yes to Question 1, please provide the cause of absence. You must also complete the Decrease in medical fitness Questionnaire.

Date you plan to return to work:

Only answer this question if you're currently off work. If you are in work move on to the next question.

Question 2. Alcohol

State your average weekly intake in units.

Question 3. Smoking.

Do you smoke?

What date did you stop smoking? (if applicable)
Question 4. Medication

Do you currently use any medication?

Details

If you answered Yes to Question 4 please provide details.

Please state the name of the medication, the dosage, the date you started taking it and why.
Question 5. Glasses or contact lenses.

If you wear glasses or contact lenses we require a report from your optician which should include the date of the examination and your visual acuity for distance and near vision. Minimum standards are 6/9 for distance vision and N5 for near vision, with or without correction. PLEASE NOTE THAT A COPY OF YOUR PRESCRIPTION WILL NOT BE SUFFICIENT IF IT DOES NOT INCLUDE THE VISUAL ACUITY VALUES.

Your application cannot be processed without this information.

Please email it to occupationalhealth@doctorcall.co.uk WITHIN 24 HOURS of filling this form. If the document has not been received within this time frame you will have to resubmit the questionnaire.

Do you wear glasses or contact lenses?

Please send us your optician report.
Go to Question 6.
Question 6.

Since your last medical assessment, have you been prescribed any long term medication? This does not include medication you are no longer taking.

Please provide details.
Go to Question 7.
Details

If you answered Yes to Question 6 please provide details.

Please provide the name of the medication, the dosage, the date when you started taking it (month and year) and the reason why.
Question 7.

Since your last medical assessment, have you had any surgical operations?

Please provide details.
Go to Question 8.
Details

If you answered Yes to Question 7, please provide details.

Please state the date and the reason for the operation.
Question 8.

Since your last medical assesment, have you had time off work for health reasons? You do not need to include minor coughs and colds or minor gastro-intestinal problems.

Please provide details.
You have finished the questionnaire - please review the details and press Submit.
Details

If you answered Yes to Question 8, please provide details:

Please provide the dates where you were unable to work for health reasons and the reason for the sickness absence.

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