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IMPORTANT - This health record or a copy of it, must be kept until the person to whom it relates has 2026
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- Click ‘Get Form’ to open it in the editor.
- In Part A, enter the employer's details including name and address. Ensure you include the post code for accuracy.
- Fill in the employee's information such as surname, forename(s), permanent address, gender, date of birth, and National Insurance number.
- Document the date of commencement as a classified person in this employment and describe the nature of employment.
- Provide details of the Approved Dosimetry Service responsible for maintaining the employee’s dose record by entering their name and address.
- 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.
- Record the result of assessment (e.g., ‘fit’, ‘fit subject to conditions’, or ‘unfit’) along with any conditions or restrictions imposed.
- Finally, ensure that the Appointed Doctor or EMA signs and includes their name in capitals along with their PIN.
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