Initial Teacher Training Form ITT 01

Statement of medical history for assessment of Teacher Training students

SECTION A and C: To be completed by prospective teacher trainees.
SECTION B: To be completed by our university medical adviser.

This form on completion should be posted to:

Dr R D Hollands
Medical Officer for University of Gloucestershire
Underwood Surgery
139 St Georges Road
Cheltenham GL50 3EQ

IN CONFIDENCE

Section A This section must be completed in full by candidate.

Section B For University of Gloucestershire medical adviser’s use only.

The University of Gloucestershire seeks to offer a place irrespective of physical or mental disabilities wherever possible, as long as they do not compromise your health, your education, your safety, or the health, safety, and welfare of pupils or trainees likely to be in your care.

The answers to any questions will not be used against you in any course decisions that will be made, either now, or in the future. A decision not to accept you on health grounds will only be taken after very careful consideration of all the fact s and will be based upon individual circumstances and the demands of your teaching career.

Candidates who are refused acceptance onto the course on health grounds have a right to a second opinion from a suitably qualified independent medical examiner.

The information contained on this form will be kept strictly confidential within the Underwood Surgery and will not be used or disclosed to any other persons without the consent of the person to whom the information relates.

Candidates should be aware that if their initial medical questionnaire is not returned by Friday 24 July 20 20 it may not be possible to complete a medical assessment before the beginning of the university year, which will impact on enrolment and access to student finance and resources.

Candidates seeking to appeal against a decision by the medical officer not to allow them to start the course must commence the appeal wihtin five working days or it may not be possible to seek a second opinion before the beginning of the university year.

Name of Applicant:

Section C This section must be completed in full by candidate

Declaration

• I certify the above information to the best of my knowledge to be true and complete.
• I understand that failure to disclose medical information now may lead to disciplinary action or dismissal in the future if I am accepted.
• I consent to the medical officer informing the universit y in the event of non-disclosure.
• I understand that I am responsible for the expenses of any medical examination or report, which may be required

Signature:

Date: