IMPORTANT - This health record or a copy of it, must be kept until the person to whom it relates has 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Part A, enter the employer's details including name and address. Ensure you include the post code for accuracy.
3. Fill in the employee's information such as surname, forename(s), permanent address, gender, date of birth, and National Insurance number.
4. Document the date of commencement as a classified person in this employment and describe the nature of employment.
5. Provide details of the Approved Dosimetry Service responsible for maintaining the employee’s dose record by entering their name and address.
6. In Part B, have an Appointed Doctor or Employment Medical Adviser complete the assessment section with the date of assessment and type of assessment conducted.
7. Record the result of assessment (e.g., ‘fit’, ‘fit subject to conditions’, or ‘unfit’) along with any conditions or restrictions imposed.
8. Finally, ensure that the Appointed Doctor or EMA signs and includes their name in capitals along with their PIN.

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