PERSONAL DETAILS FORM

Full Name:
Address & Postcode:

E mail address
Telephone No:
Mobile:

National insurance
no
Payroll number

Ward/Dept
Date of Birth:

Next of Kin:
Relationship to you:
Name:
Address:

Tel No: home

Mobile/Work

Doctor’s name:
Surgery address:

Tel Number:
 Please fill in both sides of form, Thank you

Access to Medical Files in an Emergency Situation

All staff are required to undergo a medical with Occupational Health

before joining the Trust and all information held in OH is strictly
confidential. However, in an emergency where a member of staff may
be rendered unconscious, we may need to access your records to
determine if you have a medical condition, what medication you may be
on and if you have any allergies. If you have no objections to us
accessing only the information noted above in an emergency situation,
please sign below.

*I have no objections to the Trust accessing my medical file in

Occupational Health in the event of an emergency where I
am rendered unconscious or am unable to communicate, only
to determine any medical condition I may have, what
medication I am on and any allergies I may suffer from.

OR

*I do not wish the Trust to access my medical file in Occupational

Health in any circumstances.

*Delete where appropriate

Signature: ………………………………………………………..

Date: ………………………………………………………………..