Regulations > Regulations for the Staff of the Human Rights Commission, 1996 > Schedules > Schedule A : Forms

FORM 2

HEALTH QUESTIONNAIRE

[Regulation 4(2)(b)]

Republic of South Africa	FOR OFFICIAL USE
	Accepted / rejected ............................................................................................ Signature
	Date / 19 Rank
	PROXY

1.	Surname (in block letters)

Identity No.

2.	First names

Sex

Age

Height cm

5.	Body mass kg

Do you suffer or have you suffered from—

Mark with a cross in the appropriate column

If any answer is Yes, give details of the nature, severity, date and duration thereof

1.	Any skin disease?

Yes

........................................................

2.	Any affection of the skeleton and/or joints?

Yes

........................................................

3.	Any affection of the eyes, ears, nose or teeth?

Yes

........................................................

4.	Any affection of the heart or circulatory system?

Yes

........................................................

5.	Any affection of the chest or respiratory system?

Yes

........................................................

6.	Any affection of the digestive system?

Yes

........................................................

7.	Any affection of the urinary system and/or genital organs?

Yes

........................................................

8.	Any nervous or mental affection?

Yes

........................................................

9.	Any other illness?

Yes

........................................................

1.	Do you suffer from any defect of hearing, speech or sight?

Yes

2.	Are you physically disabled and do you use artificial limbs?

GIVE DETAILS OF THE NATURE AND SEVERITY OF THE DISABILITY

......................................................................................................................................,

.......................................................................................................................................

Yes

1.	Have you undergone any operation(s)?

GIVE DETAILS OF THE NATURE AND DATE OF THE OPERATION(S)

.......................................................................................................................................

I declare that the above information is true and correct and that I have not withheld any information regarding my health and understand that any false information supplied makes me guilty of misconduct.

.............................................................

......................................................

Signature

Date

South African Human Rights Commission Act, 2013 (Act No. 40 of 2013)

Regulations

Regulations for the Staff of the Human Rights Commission, 1996

Schedules

Schedule A : Forms

Form 2 : Health Questionnaire