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FITNESS FOR WORK – MEDICATION & CONDITION DECLARATION FORM

Instructions

Employees, contractors and visitors must comply with SAF-SWP-007 Fitness for Work – Drugs & Alcohol

· Complete this form if taking prescribed or non-prescribed medication that may affect your safety & performance at work.

· Complete this form if you have a condition which may put yourself or others at risk.

· Complete this form if you have a condition which may require immediate access to medication.

· Persons using prescribed or non-prescribed medication have the following responsibilities:

· Notify the medical practitioner or pharmacist of the nature of their duties to ascertain if the side effects of a prescribed medication may impact on their safety & performance at work.

· Take any medication strictly in accordance with the medical practitioner’s or manufacturer’s recommendations.

· Notify their Supervisor of any medication they are taking that may impact on their safety & performance at work.

· Immediately report any side effects to their Supervisor.

· A new form must be completed if new medication is prescribed or previously declared medication is changed or a relevant condition becomes known.

Fitness for Work - Medication & Condition Declaration

First Name*
Last Name*
Phone*
Email*
Department*
Crew
Doctor's Name
Doctor's Phone Number
Medical Practice
Are you currently taking any prescribed or non-prescribed medications that may affect your safety & performance at work?*
- Yes
- No

Medication Declaration - List below all prescribed or non-prescribed medications you are currently taking that may affect your safety & performance at work; this form will supersede any previous medication declaration forms. Click on the + to add a new row.

Have you told the doctor/pharmacist prescribing the medication what your work is/involves?*
- Yes
- No
Has the doctor prescribing the medication told you that you are able to work whilst taking the medication as prescribed?*
- Yes
- No
Are you taking the medication as prescribed?*
- Yes
- No
If you become aware of any side effects to your work performance e.g. drowsy, not paying attention, irritability, will you advise your supervisor/Manager as soon as possible?*
- Yes
- No
Has the medication caused you to feel drowsy?*
- Yes
- No
Has the medication negatively impacted your sleep patterns?*
- Yes
- No
Does the medication carry any instructions against operating machinery?*
- Yes
- No

Condition Declaration - Condition Declaration - List below any condition/s which may affect your performance at work and/or put yourself or others at risk at work. If immediate access to medication is required please state here the type, use/dose and location of the medication (i.e. in your crib bag, etc.). This form will supersede any previous condition declaration forms. Click on the + to add a new row.

Signature - By ticking here I confirm that the information supplied regarding any medications and/or conditions in this form is correct. This form will be sent to a member of the Health and Safety Team for review and they will contact you as required.*
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