Health & Conduct Survey Form

First name

Your Warwick University Number (not your UCAS number)

Email address that you have regular and permanent access to

I do not have any health or conduct issues to declare. Go to Section C.

1. A physical impairment or mobility issue e.g. one that may prevent you from moving a collapsed patient into a safe position, or that affects your ability to write legibly by hand.

2. A mental health condition e.g. depression, anxiety, personality disorder.

3. A fit or seizure in the last twelve months.

4. Blood borne viruses. (If you do not acquire the necessary immunity you may still be admitted to study but be excluded from exposure prone procedures).

5. Any hearing impairment even if it is corrected with a hearing aid.

6. Any visual impairment not corrected by glasses or contact lenses.

7. Any other health issue(s)/condition(s) e.g. allergies, diabetes, arthritis, rheumatism.

8. Neurodiversity, e.g., Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder, Social Communication Impairments, Specific Learning Difficulties.

9. Subject to disciplinary action by a university or employer, even if the proceedings were not completed.

10. Issued with a fixed penalty notice for disorder. You do not need to declare other fixed penalty notices e.g. driving, traffic and minor offences like fare evasion or littering.

11. A spent or current caution(s) and/or criminal conviction(s). You do not need to declare any formal cautions and convictions if they are protected by law in the UK.

12. A current or future proceeding that may lead to a caution or conviction.

13. Refused registration or a licence to practise by any Professional, Statutory or Professional Body.

14. Subject to any fitness to practise investigation(s) or hearing(s) by any Professional, Statutory or Professional Body, even if the proceedings were not completed.

Supporting documentation

Attach file

No files are currently attached.

Additional Information – Please indicate which declaration statement it refers to:

I confirm that the information given by me in this Health and Conduct Survey is true and complete to the best of my knowledge.

Privacy notice

The University of Warwick will process your personal data provided on the Health and Conduct Survey to meet a condition of the offer of a place to study on the WMS MB ChB course. If you do not take up a place at WMS, all Health and Conduct Survey information you have provided will be destroyed. The legal basis for processing your personal data is that it is necessary for the performance of a contract. This data will be used in relation to any Health, Welfare and Professionalism (HWP) and fitness to practise (FtP) concerns that arise during the course. It will not be shared with any third parties external to the University of Warwick except when you have been referred to the Fitness to Practise Panel (MBChB). In this case, your FtP and HWP data will be shared in any fitness to practise requests from any recognised professional, statutory or regulatory bodies and provided to the GMC in the Student Fitness To Practise Annual Return. If you are excluded from the MB ChB Course, your data will be entered into the Medical Schools’ Council's Excluded Students' Database. Your HWP and FtP data will be kept securely by the University of Warwick in accordance with the University's Records Retention Schedule.

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at infocompliance@warwick.ac.uk.

WMS MB ChB Current Students

Health & Conduct Survey Form

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