[Enter name and address of doctor]
Private and confidential
Dear [insert name of doctor],
Request for pre-employment medical [examination and] report
We have made a conditional offer of employment to [employee’s name] as a [insert job title]. One of the conditions is that we are satisfied of their fitness to undertake the duties of this role.
The role involves [insert details of the duties of the role, including details or any particular hazards to which the employee may be exposed e.g. manual handling, use of chemicals, vapours].
This letter confirms our instructions to you to produce a report on their fitness to undertake the above duties, either with or without reasonable adjustments and whether they suffer from any medical condition which might result in us being under a legal obligation to make reasonable adjustments [as well as our arrangement for you to examine them at [insert time] on [insert date] at [insert address]].
Please include consideration some/all of the following matters within the scope of your report, plus any more that you feel are appropriate:
• Does the individual have any current health problems?
◦ If so, when were they diagnosed/first apparent?
◦ What is the prognosis of the condition?
• Do they have a physical AND/OR mental impairment?
◦ If so, does this impairment affect their ability to undertake normal day-to-day activities?
◦ If so, how long has the impairment lasted and how long is it likely to last?
• Have they had any previous significant long-term health problems?
◦ If so, has this impacted on their ability to work in the last 5 years (beyond normal amounts of sickness absence)?
• Would any modifications to their duties/hours be necessary because of health problems?
We enclose a form completed by the individual, consenting to:
• our obtaining a medical report from you
• [undergo a medical examination by you]
• [your being given access to their medical records by their doctor whose contact details are [insert name] of [insert address]]
• your discussing your findings with us after producing your report
• the processing of their sensitive personal data required in order to carry out the above, as required under the Data Protection Act 1998
We are also sending them a copy of this letter and will send them a copy of your report in due course.
We look forward to receiving your report as soon as possible, together with a note of your fees, which we agreed would not exceed £[insert amount].
[insert name of employer’s representative]
cc [insert name of employee]
Encl: completed consent form for [insert name of employee]