Gas Regulator Levies Act, 2002
R 385
South African Human Rights Commission Act, 2013 (Act No. 40 of 2013)RegulationsRegulations for the Staff of the Human Rights Commission, 1996SchedulesSchedule A : FormsForm 2 : Health Questionnaire |
FORM 2
HEALTH QUESTIONNAIRE
[Regulation 4(2)(b)]
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Republic of South Africa |
FOR OFFICIAL USE |
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Accepted / rejected
............................................................................................ Signature |
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Date / 19 Rank |
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PROXY |
| A. |
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Identity No. |
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Sex |
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| B. |
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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 |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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| C. |
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Yes |
No |
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GIVE DETAILS OF THE NATURE AND SEVERITY OF THE DISABILITY |
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......................................................................................................................................, ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... |
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| D. |
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Yes |
No |
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GIVE DETAILS OF THE NATURE AND DATE OF THE OPERATION(S) |
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....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... |
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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.
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