Pre-Employment Health Declaration Form

Employment at NIIT is based on the applicant being suitable for the position and is fully able to perform
as per the requirements of the position. The purpose of the pre-employment health declaration is to take
appropriate and reasonable action to ensure your health, safety and wellbeing. The intent is not to deny
your employment solely because of disability, illness or injury. You must fill out the health declaration
form keeping in mind the position you have applied for.

Privacy
Your privacy is important. All details provided on this form are treated confidentially. The completed
health declaration form will be retained on your personnel file in a secure manner.

Full Name: MADDIREDDY NARASIMHULU

Date of Birth: 10-05-1990

Contact Number (Mobile) 9391307519

Contact Number (Alternate) 9606237982

Email address: narasimhulum2421@gmail.com

Home Address: Padakandla village, Atmakur Mandal, Sri Potti Sriramulu Nellore District,
Andhra Pradesh
Postal code: 524307

Position applied for :

Business Unit:
Work Location: Bangalore

You are required to disclose any pre-existing disease, injury, aliment or condition that you have suffered
or continue to suffer and could be affected by the nature of the proposed employment.

YES NO
Any physical or mental condition that might affect your ability to do or be NO
made worse by doing the job you have applied for?
Any physical or mental health condition that might affect your safety or the NO
safety of others at work?
Do you need any adjustments made to your workplace, workplace NO
equipment or working practices?
Have you been retired or had your work contract terminated due to ill health? NO

Have you ever applied for or been awarded compensation for a workplace NO
injury or illness?
Any other condition or health problem that the Occupational Health Unit NO
should be made aware of or you want advice about?
 Have you been admitted to a hospital during the last 2 years for any YES NO
medical treatment? If YES, give details of disease, # of days stayed in the
hospital.
Details of hospitalization including disease

Have you been detected with any of the critical diseases listed below YES NO

Kindly confirm your COVID Vaccination status by ticking the relevant section in the below table -

Not Vaccinated

First COVID Shot YES

Fully Vaccinated

Infected & Vaccination due after isolation period

I Maddireddy Narasimhulu confirm that to the best of my knowledge, the answers

given above are true and correct. I also confirm that I have read and understood the terms in the
appointment letter regarding ‘medical fitness & verification of particulars’ before making the above
declaration. I also understand that failure to disclose any relevant information may result in serious action
including termination of the employment contract.

Signature: … ……………… Date: 05-01-2022

List of Critical Diseases

1. CANCER OF SPECIFIED SEVERITY
2. MYOCARDIAL INFARCTION
3. OPEN CHEST CABG
4. OPEN HEART REPLACEMENT OR REPAIR OF HEART VALVES
5. COMA OF SPECIFIED SEVERITY
6. KIDNEY FAILURE REQUIRING REGULAR DIALYSIS
7. STROKE RESULTING IN PERMANENT SYMPTOMS
8. MAJOR ORGAN /BONE MARROW TRANSPLANT
9. PERMANENT PARALYSIS OF LIMBS
10. MOTOR NEURON DISEASE WITH PERMANENT SYMPTOMS
11. MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS
12. ANGIOPLASTY
13. BENIGN BRAIN TUMOR
14. BLINDNESS
15. DEAFNESS
16. END STAGE LUNG FAILURE
17. END STAGE LIVER FAILURE
18. LOSS OF SPEECH
19. LOSS OF LIMBS
20. MAJOR HEAD TRAUMA
21. PRIMARY (IDIOPATHIC) PULMONARY HYPERTENSION
22. THIRD DEGREE BURNS