HEALTH ASSESSMENT FORM

This assessment is to be completed before any sick personnel is allowed back into the office
space and is for the assessor alone. (to be completed by the supervisor of individual sick)

Name of Individual: ADEWOYE TAIWO RACHEAL

Branch: OJODU

Job Function: CIS

Absence Start Date: 6TH OF MAY, 2020

1. What was the complaint/symptoms?

a. PREGNANCY
b. ABDOMINAL PAIN
c. VOMITING AND LOST OF APPETIDE

2. When did this start? MARCH ENDING

3. While away from work, where did you go (hospital/home/pharmacy)? HOSPITAL

a. Did you see a doctor or someone else for treatment? I SAW A DOCTOR

4. Where you admitted in hospital (Yes/No)? YES

a. What is the name of the hospital? OGUN STATE UNIVERSITY TEACHING
HOSPITAL (OSUTH)
b. How long were you there on treatment? FOUR WEEKS (4)
c. What was the nature of the treatment given? MALARIA, TYPHOID AND
DIAGNOSIS OF APPENDICTIS

5. For how long have you been away from work? 6TH OF MAY, 202O
a. From which location did you last work, home or office? OFFICE

6. Do you still have the symptoms observed earlier (Yes/No)? Please give details: NO, I
have been treated at the hospital and I was administer with some anti-biotic drugs and
injections by the doctors and now I have recovered

Comments by Team Lead/Line Manager/Group Head:

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Name: ……………………………………………… Signature & Date: ………………………………………………..