EUSR Health Form

Health Screening Questionnaire

All personnel employed to work on Restricted Operations have a responsibility to ensure they do not contaminate water supplies. This questionnaire is designed to obtain brief information regarding medical history.

Do you at present, or have you suffered during the last 12 months, from any of the illnesses listed below?

• Typhoid
• Paratyphoid
• Dysentery
• Persistent diarrhoea or vomiting
• Jaundice or Hepatitis (A or E)
• Prolonged unexplained fever

If ‘Yes’ is selected, medical clearance must be obtained before the application can be submitted to EUSR.

Declaration – to be completed by the individual

I certify that I have answered the Health Screening Questionnaire honestly and that, where appropriate, I will seek the relevant medical clearance.

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