Pre-Employment Health Declaration

I. Introduction

This Pre-Employment Health Declaration is a crucial step in ensuring the safety and well-being of our employees and maintaining a healthy work environment at [YOUR COMPANY NAME]. As part of our commitment to health and safety, we require all prospective employees to complete this declaration prior to commencing employment.

II. Personal Information

Please provide the following details accurately:

• Name: [YOUR NAME]

• Date of Birth: [YOUR DATE OF BIRTH]

• Address: [YOUR ADDRESS]

• Contact Number: [YOUR CONTACT NUMBER]

• Email Address: [YOUR EMAIL ADDRESS]

III. Health Status Declaration

By signing this declaration, you confirm that:

You are in good health: You assert that you are not aware of any medical condition or illness that would prevent you from performing the duties of the position for which you are applying at [YOUR COMPANY NAME].

You have not been diagnosed with any contagious diseases: You affirm that you have not been diagnosed with any contagious diseases, including but not limited to COVID-19, in the past [SPECIFY TIMEFRAME].

You have not traveled to high-risk areas: You declare that you have not traveled to any regions identified as high-risk for infectious diseases within the specified timeframe.

You will adhere to health and safety protocols: You commit to adhering to all health and safety protocols implemented by [YOUR COMPANY NAME], including regular health screenings and hygiene practices.

IV. Acknowledgment of Consequences

You understand that providing false or misleading information in this declaration may result in disciplinary action, up to and including termination of employment, if discovered at any point during your employment with [YOUR COMPANY NAME].

V. Consent for Verification

By signing this declaration, you consent to [YOUR COMPANY NAME] verifying the information provided herein, including contacting relevant medical professionals or institutions if necessary, to confirm your health status.

This declaration is valid for the purposes of employment with [YOUR COMPANY NAME] and may be subject to review and update as deemed necessary by the company's policies and regulations.

VI. Indemnity

You indemnify and hold harmless [YOUR COMPANY NAME], its officers, directors, employees, and agents from any claims, damages, or liabilities arising out of or related to the accuracy or completeness of the information provided in this declaration.

VII. Governing Law

This declaration shall be governed by and construed in accordance with the laws of [YOUR JURISDICTION], without regard to its conflict of law principles.

VIII. Signature

I hereby declare that the information provided in this Pre-Employment Health Declaration is true and accurate to the best of my knowledge.

Signature:

[YOUR NAME]
[DATE]

Declaration Templates @ Template.net