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Medical declaration form template

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A medical declaration form to disclose information that may impact an ability to perform tasks or may require adjustments to ensure workplace safety.

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What is a Medical declaration form?

The purpose of an employee medical declaration is to gather relevant health-related information from employees to ensure their well-being and safety in the workplace. It serves several important purposes:

  1. Health and Safety: An employee medical declaration helps employers identify any medical conditions, disabilities, or health-related limitations that may require accommodations or adjustments to ensure a safe working environment. It allows employers to assess potential risks and implement appropriate measures to protect the health and safety of the employee and others in the workplace.

  2. Duty of Care: Employers have a legal duty of care towards their employees. By implementing a medical declaration, employers demonstrate their commitment to understanding and addressing any health issues that could impact an employee's ability to perform their job safely and effectively. It helps ensure that employees receive the necessary support, accommodations, or reasonable adjustments to carry out their work without compromising their health.

  3. Risk Assessment: An employee medical declaration provides valuable information for conducting risk assessments. By knowing about an employee's medical conditions or limitations, employers can identify potential hazards and implement preventive measures to mitigate risks. It allows employers to tailor their health and safety policies and procedures to address specific health concerns within the workforce.

  4. Compliance with Legislation: Gathering employee health information through a medical declaration helps employers meet legal obligations, such as providing reasonable accommodations under the Equality Act 2010. It demonstrates a proactive approach to complying with employment and health and safety regulations by addressing potential risks and ensuring equal treatment for employees with disabilities or health conditions.

  5. Planning and Support: The information obtained from a medical declaration enables employers to plan and allocate resources effectively. It assists in workforce planning, employee support programs, and the provision of necessary adjustments or accommodations to facilitate the employee's well-being, productivity, and job satisfaction.

It's important to note that an employee medical declaration should be handled with strict confidentiality and in compliance with data protection regulations to safeguard the privacy and security of employee health information.

Here are some specific instances when it should be issued:

  1. Pre-Employment: As part of the recruitment process, an employee medical declaration can be requested to assess an individual's fitness for the specific job role. This helps identify any potential health-related limitations that may affect their ability to perform essential job functions or require reasonable accommodations.

  2. Health and Safety Risk Assessment: If there are significant health and safety risks associated with a particular job or workplace environment, employers may require employees to complete a medical declaration. This ensures that employees are fit to carry out their duties safely and that any necessary adjustments or safeguards are in place.

  3. Changes in Health Condition: When an employee's health condition changes significantly or they acquire a new medical condition, it is essential to issue a medical declaration. This allows employers to reassess the employee's ability to perform their job and determine if any adjustments or accommodations are necessary.

  4. Return-to-Work: After a prolonged absence due to illness, injury, or disability, employers may request an employee medical declaration before the employee returns to work. This helps ensure that the employee is medically fit to resume their duties and allows employers to make any necessary arrangements or accommodations.

  5. Periodic Health Assessments: In some industries or job roles, periodic health assessments may be required to monitor the overall health and well-being of employees. This can help identify any work-related health risks or conditions that may require intervention or adjustments to prevent further health issues.

Medical declaration form template
medical declaration form template

What legal and best practice aspects should employers be aware of?

Adjustments may include physical adaptations, or adjustments to working arrangements such as hours. Where the candidate has answers ‘Yes’ to any of the questions in the declaration, you might want to also involve an Occupational Health Service (OHS) who may provide further advice.

  • Equality Act 2010: The Act prohibits discrimination on the grounds of disability and requires employers to make reasonable adjustments for employees with disabilities. Implementing an employee medical declaration can help employers gather relevant information to assess and provide appropriate accommodations.
  • Health and Safety at Work Act 1974: This legislation places a duty on employers to ensure the health, safety, and welfare of their employees. Implementing a medical declaration can help identify any health conditions or limitations that may require specific measures to maintain a safe working environment.
  • Data Protection Act 2018: This legislation governs the processing of personal data and sets out principles for handling sensitive information. Employee medical declarations should comply with data protection regulations to ensure the privacy and security of employee health information.
  • Access to Medical Reports Act 1988: This Act regulates the access to medical reports by employers and provides guidelines for obtaining and handling employee medical information. It supports the implementation of medical declarations by establishing a legal framework for requesting and using medical information.
  • Management of Health and Safety at Work Regulations 1999: These regulations require employers to conduct risk assessments and take appropriate measures to protect employee health and safety. Implementing an employee medical declaration can contribute to a comprehensive risk assessment process by identifying potential health risks or conditions that may require specific precautions or adjustments.
  • Employment Rights Act 1996: This Act outlines various employment rights, including the right to a safe and healthy working environment. Implementing a medical declaration helps employers fulfill their duty of care towards employees' health and well-being.
  • General Data Protection Regulation (GDPR): Although not specific to employment, GDPR sets out requirements for processing personal data, including health-related information. Employers need to ensure that employee medical declarations comply with GDPR principles, such as obtaining consent, maintaining data accuracy, and protecting data security.

Medical declaration

Employee Information:

  • Name: [Employee Name]
  • Job Title: [Employee Job Title]
  • Department: [Employee Department]
  • Date of Employment: [Date of Employment]

Health Information:

Please provide accurate and complete information regarding your health. This information will be treated confidentially and will only be used for occupational health and safety purposes.

Question Response
1. Do you have any pre-existing medical conditions that may affect your ability to perform your job duties? [Response]
2. Are you currently taking any medications or undergoing any medical treatments? [Response]
3. Have you had any recent surgeries or hospitalizations? [Response]
4. Do you have any allergies or sensitivities to medications, substances, or environmental factors? [Response]
5. Have you ever been diagnosed with or received treatment for a contagious or infectious disease? [Response]
6. Have you ever had a work-related injury or illness? [Response]
7. Are you aware of any physical or mental health conditions that may require accommodation or adjustments in the workplace? [Response]
8. Have you been advised by a healthcare professional to make any modifications to your work environment or job duties? [Response]

I declare that the information provided above is true and accurate to the best of my knowledge. I understand that any false or misleading information may result in disciplinary action, up to and including termination of employment.

Employee Signature: _______________________ Date: _______________________

Please return this completed form to the Human Resources Department. If there are any changes to your health status in the future, it is your responsibility to update this information promptly.

Version: [1.0]

Issue date: [date]


The Medical declaration form template is issued by an employer
Issue path
The Medical declaration form template is issued to an employee


An employee medical declaration should typically be issued during the pre-employment stage, as part of the onboarding process, or when an employee's health condition changes significantly.

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