OCCUPATIONAL HEALTH DEPARTMENT

VOLUNTEER FITNESS STATUS

NOTE TO APPLICANT:

THIS FORM IS TO BE FILLED OUT BY THE PRINCESS ROYAL HOSPTIAL OCCUPATIONAL HEALTH DEPARTMENT. Please put this form in a separate envelope with the Occupational Health Questionnaire and address the envelope “Occupational Health Department” and return with the completed application form.

To: Membership Secretary

Address: Mid Downs Hospital Radio

Princess Royal Hospital

Applicants name:

Volunteer to work with Mid Downs Hospital Radio

I am now in receipt of the Occupational Health Questionnaire for the above named person and I would like to advise you that he / she is :

r FIT FOR THE PROPOSED POST

r FIT WITH THE FOLLOWING MODIFICATIONS:

r TO BE SEEN FOR A PRE-EMPLOYMENT HEALTH INTERVIEW ON ______________

r UNFIT

Name:

Signature:

Date: