4.15 Night Time Worker Health Assessment Questionnaire

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CONSENT AND DECLARATION

I give my consent for MOHS Workplace Health Ltd to carry out a health assessment for night time working. I understand that this is necessary for health and safety reasons and the results of this assessment, including recommendations (but not the detailed medical findings) will be given to my employer, to assist in maintaining a healthy and safe workplace. I declare that, to the best of my knowledge, the information given above and in the answers to the health questionnaire is true and complete. I understand that failure to disclose relevant information or providing false information may affect my employment.

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