Worker Self - Registration

During your employment with Simple Recruitment Solutions, you may be placed on various assignments, with a variety of job roles. This may place different physical and/or mental demands upon you. To allow us to support you fully, and ensure your wellbeing and safety it is important that you answer the questionnaire below honestly, if you have any concerns or questions, please do not hesitate to discuss these with us.

Do you suffer from or have you

1. Any Allergies or sensitivity to certain substances *

2. Heart Disease, Circulatory disorder or high blood pressure *

3. Asthma *

4. Fits, blackouts, or epilepsy *

5. Any back, neck or other muscle problems *

6. Trouble bending or lifting *

7. Bowel disorders *

8. Hearing problems *

9. Rupture, varicose veins or foot ailments *

10. Eye disease, injuries or vision issues not corrected by spectacles or contact lenses *

11. Diabetes *

12. Mental health conditions including stress & depression *

13. Anxiety / panic attacks *

14. A pacemaker *

15. Any condition or disability not included on this form *

16. Currently taking medication, receiving injections ( other than contraceptives) *

Night Working - Have you or do you suffer from?

17. Any condition which may be affected by your night working *

18. Any condition which requires medication or meals to a strict timetable *

19. Any sleeping disorder or difficulty sleeping *

20. If you have answered yes to any of the above, please provide more information

The above information is accurate, I understand that providing false information would be considered gross misconduct and may result in disciplinary action unto and including dismissal. I consent that Simple Recruitment Solutions will process my data for legitimate business purposes including absence monitoring and health and safety management. I understand that it will be retained for as long as required to allow the company to comply with its statutory obligations. I also understand that if there are any changes to this, I will inform Simple Recruitment Solutions.

21. Signature - *

Clear

22. Date - *

Declaration

I confirm that Simple Recruitment Solutions have my permission to obtain references as required and can contact my current and previous employers as detailed above. I understand and consent to Simple Recruitment Solutions disclosing my personal information which is relevant to my work and immigration status as required to relevant third parties for the purposes of finding work (legitimate interests) and complying with any authority for legal purposes. I am happy for Simple Recruitment Solutions to disclose my information to clients for the purposes of audits which will include sensitive personal information such as application pack, eligibility to work, criminal history, references and copies of licences and specialist qualification documents. I conform that the information given above is correct and can be confirmed by way of references. I declare I have no unspent criminal convictions, other than those listed within this document, and no pending prosecutions. I am aware that it is my responsibility to ensure I am wearing appropriate safety clothing and PPE on all assignments.I give permission for Simple Recruitment Solutions to provide my personal contact details and personal information such as mobile telephone number to clients with whom I am assigned to. I understand the terms of payroll and that all assignments are paid one week in arrears into my bank account as per details supplied.

I understand and acknowledge by submitting bank details I am requesting Simple Recruitment Solutions to pay wages / invoices due into the names and numbered account provided.

I understand that by supplying my email address to Simple Recruitment Solutions I will receive the following information by email Important Assignment information - including information relating to assignments which I undertake on behalf of Simple Recruitment Solutions including Health & Safety Information and changes to procedure etc. I hereby confirm that I am willing to receive SMS messages from Simple Recruitment Solutions regarding changes to my shift times / location / client throughout my assignment including during rest periods and am required to confirm acceptance. I do not consider these messages to be a break of my rest period under the WTD

1. Signature - *

Clear

2. Print Name *

3. Date - *

WTD Opt-Out

The Working Time Regulations (1998) state that an employee cannot be expected to work in excess of 48 hours per week, on average. By signing this form, you opt out of the 48 hour limit on working time as stated in the Working Time Regulations, on the understanding that if you work over 48 hours per week it is your choice to do so. You understand that in the event that you wish the 48-hour limit to apply to your employment in the future you will be required to notify the Company in writing. I understand that by opting out of the 48-hour limit on working time, I may still work in excess of 48 hours per week on average, but this is my choice to do so. If I wish the 48-hour limit to apply to my employment in the future I am required to notify the company in writing.

1. Signature - *

Clear

2. Print Name - *

3. Date - *