Rochestown Park Hotel

Pre-Employment Screen
Name: Department: Start Date:

MEDICAL INFORMATION:

Please list any serious illnesses that you have currently or been previously diagnosed with or any
serious accidents that you may have had.

I don't have diseases, nor do I suffer accidents.

Have you attended hospital within the last two years? Yes yes No_________
If yes – why? Yes, do periodic exams.
_________________________________________________________________

Is there any health related reason why you may not be able to fully carry out all duties that may
be required for the position you have applied for, if so, please detail
Not

Are you currently suffering from, or have you ever suffered from, any of the illnesses listed
below?

Heart trouble Lung disease Dietary Condition

Yes X No Yes X No Yes X No

Back / neck problems Joint problems/arthritis Headaches/migraines

Yes X No Yes X No Yes X No

Diabetes Serious allergies Skin problems

Yes X No Yes X No Yes X No

Serious accident/injury Blood pressure Asthma

Yes X No Yes X No Yes X No

Fits/blackouts/epilepsy Depression/anxiety Hearing/sight problems

Yes X No Yes X No Yes X No

Neurological disorder
Yes X No

If you have answered ‘yes’ to any of the questions above, please give further details and
approximate dates where relevant.:
…………………………………………………………………………………………………………………………………………………………………………
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…………………………………………………………………………………………………………………………………………………
 Is there anything else in your medical history or circumstances which might affect our
decision to offer you employment?:…………………………………………………………................................
………………………………………………………………………………………………………………………………………………………

Are you willing to undergo a medical examination by the Hotel doctor-?

Yes X No

The hotel reserves the right to send you for a medical examination at any point during
your employment.

I hereby declare that the information given is full and true to the best of my knowledge. I
understand that if at a later date, it is discovered that I have knowingly withheld medical
information, disciplinary action may be taken against me, which may include dismissal. If I
have not yet started employment, any job offer may be withdrawn.

Signature:…………………………………………………………….Date 09/09/2022

Data Protection Clause:

All personal information provided on this application form will be stored securely by the organisation and will be used for
the purposes of the recruitment process.
All forms will be retained for a period of 6 months, and in the case of a successful candidate for the duration of his or her
employment and a minimum of one year thereafter.
This information will not be disclosed to any third party without your consent, except where necessary to comply with
statutory requirements or to provide normal services.
Internally, your information will be kept confidential and only made available as necessary. You may, at any time, make a
request for access to the personal information held about you.
Should you wish to make any changes, or erasures, to any of the information stored about you, please contact the HR
department.

Background Check:
Have you ever been convicted of a criminal offence? Yes X No

If yes please detail

___________________________________________________________________

_____________________________________________________________________

Is there currently a case outstanding against you? Yes X No

If yes – please give details

I hereby declare that the information given is full and true to the best of my knowledge. I
understand that if at a later date, it is discovered that I have knowingly withheld information
on the above, disciplinary action may be taken against me, which may include dismissal.
If I have not yet started employment, any job offer may be withdrawn

Signature:…………………………………………………………….

Garda Vetting

Have you been Garda vetted in the past? Yes No

The National Vetting Bureau (Children and Vulnerable Persons) Acts 2012-2016 make it
mandatory for people working with children or vulnerable adults to be vetted by the Garda
Síochána National Vetting Bureau.

Vetting is applicable to all roles in the Leisure Centre department.

09/09/2022

Applicant’s signature Date

Data Protection Clause:

All personal information provided on this application form will be stored securely by the organisation and will be used for
the purposes of the recruitment process.
All forms will be retained for a period of 6 months, and in the case of a successful candidate for the duration of his or her
employment and a minimum of one year thereafter.
This information will not be disclosed to any third party without your consent, except where necessary to comply with
statutory requirements or to provide normal services.
Internally, your information will be kept confidential and only made available as necessary. You may, at any time, make a
request for access to the personal information held about you.
Should you wish to make any changes, or erasures, to any of the information stored about you, please contact the HR
department.