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INSTITUTE OF EDUCATION (DIDSBURY)

      Physical and Mental Fitness of Entrants to Early Years Professional Status




Ca...
CANDIDATES FOR COURSES OF INITIAL TEACHER TRAINING & EARLY
                YEARS PROFESSIONAL STATUS

                    ...
YES or NO   PLEASE GIVE DETAILS   DATES
                                                                   WHERE APPROPRIA...
f   heart trouble, rheumatic fever, high blood
      pressure or poor circulation?

  g asthma, bronchitis, tuberculosis, ...
9         Have you required a doctor during the last 5 years?                                              Yes            ...
CANDIDATE NAME: ………………………………………………

       Action Box

a
                           Fit/Suitable on information given

b
 ...
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Declaration Of Health

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Declaration Of Health

  1. 1. INSTITUTE OF EDUCATION (DIDSBURY) Physical and Mental Fitness of Entrants to Early Years Professional Status Candidates for courses Early Years Professional Status and Initial Teacher Training need a high standard of physical and mental health to enter the teaching profession. Teaching is a demanding career and teachers have to act in loco parentis for the pupils in their charge. The health, education, safety and welfare of pupils are important factors in deciding on an individual’s fitness to teach. The completion of the attached medical questionnaire is, therefore, a requirement for all candidates entering courses of teacher training. Only in exceptional cases is a medical examination required. Full details of the medical requirements for teaching are contained in Circular No 4/99 ‘Physical and Mental Fitness to Teach of Teachers and of Entrants to Initial Teacher Training’ issued by the Department for Education and Employment. Copies of the Circular are available from: DfEE Publications PO Box 5050 Sudbury Suffolk CO10 6ZQ Tel: 0845 602 2260 Fax: 0845 603 3360 This form should be completed and returned in a separate sealed envelope with your name and course on the front and marked ‘Medical and Confidential - EYPS’ to: Manchester Metropolitan University Centre for Innovation & Enterprise Didsbury Campus 799 Wilmslow Road Manchester M20 2RR
  2. 2. CANDIDATES FOR COURSES OF INITIAL TEACHER TRAINING & EARLY YEARS PROFESSIONAL STATUS DECLARATION OF HEALTH MEDICAL - IN CONFIDENCE 1. MR/MRS/MISS/MS (please delete) SURNAME (in block letters) .................................................................................................. FORENAME ........................................................................................................................... OTHER NAMES (if applicable)……………………………………………………..…….… ADDRESS ................................................................................................................................ ..................................................................................................................................................... .................................................................................................................................................... POSTCODE ................................................. HOME TELEPHONE NO: ....................................... WORK NO: ............................................ MOBILE NO: ……………………………… DATE OF BIRTH………………………….. 2. COURSE TITLE .................................................................................................................... SUBJECT ............................................................................................................................... AGE RANGE (if applicable...................................................................................................... 3. HEIGHT (without shoes) ......................................................................................................... WEIGHT....................................................................................................................................
  3. 3. YES or NO PLEASE GIVE DETAILS DATES WHERE APPROPRIATE 4 a Is your eyesight satisfactory for all normal purposes? (With glasses or contact lenses if necessary) b Are you able to recognise and distinguish all the various colours? c Is your hearing in each ear good for all normal purposes including telephoning? d Are you free from any writing defect or dyslexia? e Are you free from any defect of speech or communication problem? f Are you free from any other physical defect or disability? g Are you now generally in good health? 5 a Are you at present under any medical treatment or observation (including alcohol/drug related problems)? b Do you smoke? c Are you at present taking any medicines, pills, tablets or injections? d Have you ever had any treatment in hospital, undergone any operation or had a serious accident? (Please attached a separate sheet if necessary) e Have you ever had treatment by radium or radiotherapy or with chemotherapy? 6 Do you need, or would it assist you, to have any special provision made to enable you to fulfill your training and/or subsequent employment? 7 Have you ever had: a migraine or recurrent headaches? b fits, fainting attacks, blackouts or epilepsy? c mental ill health, nervous breakdown or nervous disability or psychiatric problems? d depression? e paralysis or other neurological disorders?
  4. 4. f heart trouble, rheumatic fever, high blood pressure or poor circulation? g asthma, bronchitis, tuberculosis, serious cough or other chest disease? h gastric or duodenal ulcer or other digestive or bowel disorder? i kidney disease or bladder trouble? j menstrual or gynaecological problems? k arthritis, rheumatism, joint problems? l any back trouble, including slipped disc or bone problems? m any blood disease? n any eczema or skin disease? o any allergy? p diabetes? q thyroid or gland problems? r eye disease? s ear disease, including running from the ears? t vertigo, giddiness or tinnitus (ringing in the ears)? u hernia or rupture? v varicose veins? w any alcohol or drug related problem or illness? x any recurrent infections? y any other illness? 8 a Have you ever been refused employment or rejected for medical reasons? b Have you ever left employment on grounds of ill-health or unsatisfactory attendance?
  5. 5. 9 Have you required a doctor during the last 5 years? Yes No If yes, please give details: Nature of illness Dates of beginning and end of Number of weeks unable to illness attend school, college or to follow usual occupation 10 May we approach your family doctor and if necessary your hospital specialist for further information? Yes No Please give the name and address of your family doctor and hospital specialist(s): DOCTORS NAME ................................................................................................................................................ ADDRESS ............................................................................................................................................. ................ .................................................................................................................................................................... .............. SPECIALIST NAME ................................................................................................................................ ............. ADDRESS .................................................................................................................................................. ........... ......................................................................................................................................................................... ........ . 11 a I declare that the information I have given is to the best of my knowledge and belief true and complete. b I understand that I may be responsible for the expenses of any medical examination or report which may be required. c I understand that I may be required to attend a medical examination. d I understand that failure to disclose information, or giving false information, may result in termination of my course and subsequently of my employment. SIGNED ................................................................................ DATE ....................................... ......... ………………………………………………………………………………………………………… 12 To be completed by Occupational Health Department/College Medical Advisor
  6. 6. CANDIDATE NAME: ……………………………………………… Action Box a Fit/Suitable on information given b Further information required Letter to GP Letter to Specialist (s) Medical Examination Required Reply from GP Report from Specialist (s) Date of Examination Copy Form GP Report Specialist Report Sent to DES Medical Advisor for Advice Reply from DES Medical Advisor Final Result Suitable/ Fit Suitable/Not fit Category A, B or C For office Use Only: Approved: Yes/No Doctors Signature/Stamp ……………………..…………………….. Return to: Centre for Innovation & Enterprise, MMU Didsbury, 799 Wilmslow Road, Didsbury, M20 2RR.

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