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Fitness-To-Work Assessment Form Template

This form template can help employers assess an employee’s fitness to perform their job. It covers physical, mental and emotional factors, and can be customized to fit the needs of any organization. With this form, employers can quickly and easily evaluate an employee’s readiness for work.

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Fitness To Work
General Information
Name of Employee
Date of Assessment
Reason for Assessment
Have you suffered from diarrhoea and/or vomiting within the last 48 hours?
At present are you suffering from:
infected wounds, skin infections or sores?
boils, styes or septic fingers?
discharge from eye, ear or gums/mouth?
Have you ever had, or are you known to be a carrier of typhoid or paratyphoid?
In the last 21 days have you been in contact with anyone, at home or abroad, who may have been suffering from typhoid or paratyphoid?
If the answer to any question is ‘yes’, the individual should not be permitted to handle food or enter food handling areas if there is any likelihood of direct or indirect contamination. Further advice should be sought e.g. from your Environmental Health Officer and/or Doctor.
Action Taken
Owner's/Manager's Signature
I hereby declare that the information I have given is correct and I undertake to notify my employer/manager if I suffer from any of the above illnesses/conditions.
Employee's Signature
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This Fitness-To-Work Assessment Form Template is a comprehensive and easy-to-use tool used to evaluate an individual’s physical capabilities for a specific job. It covers a wide range of factors including job duties, physical requirements, medical history, and overall health and wellness. The form enables the employer to accurately assess the employee’s ability to perform the job and make informed decisions about their hiring. It also helps to ensure that the employee is fit for the job, and provides evidence that the employer has taken all reasonable steps to protect the employee’s health and safety.
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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