Fillable APPENDIX FOUR SELF-CERTIFICATION MEDICAL REPORT (Ashfield District Council)

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APPENDIX FOUR SELF-CERTIFICATION MEDICAL REPORT (Ashfield District Council)

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APPENDIX FOUR
SELF-CERTIFICATION MEDICAL REPORT
(RENEWAL APPLICATIONS ONLY)
HACKNEY CARRIAGE & PRIVATE HIRE (DUAL) DRIVER LICENCE
Unless you have been requested to undertake a Group II Standard Medical Examination
on renewal of your Hackney Carriage & Private Hire (Dual) Driver Licence, you are required
to complete and submit this Self-Certification Medical Report.
The Licensing Authority reserves the right to request a further Group II Standard Medical
Examination be carried out, where it is deemed appropriate (i.e. where there are health
issues that require frequent monitoring, or where an existing health issue may give rise to
concerns over the safety of the driver, his / her passengers, and / or other road users /
members of the public).
This Self-Certification Medical Report must be provided to the Licensing Authority when
submitting your application to renew your Hackney Carriage & Private Hire (Dual) Driver
Licence by way of a pre-booked appointment with a Licensing Officer.
APPLICANTS DETAILS
FULL NAME:
ADDRESS:
POSTCODE:
CONTACT TEL. NO.:
EMAIL ADDRESS:
DATE OF BIRTH:
HC & PH (DUAL) DRIVER LICENCE NO. (BADGE):
HAVE THERE BEEN ANY CHANGES TO YOUR HEALTH / MEDICATION SINCE YOU LAST
SUBMITTED A GROUP II STANDARD MEDICAL CERTIFICATE TO THE COUNCIL?
YES NO (tick the appropriate box)
IF YOU HAVE ANSWERED “YES”, PLEASE GIVE DETAILS BELOW:
PLEASE NOTE: IT IS AN OFFENCE TO FAIL TO DECLARE SUCH MATTERS
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PLEASE PROVIDE THE DETAILS OF THE DOCTOR AND THE SURGERY WHERE THEY
PRACTICE (THIS SHOULD BE THE DOCTOR WITH WHOM YOU ARE REGISTERED WITH).
DOCTOR’S NAME:
SURGERY ADDRESS:
POSTCODE:
SURGERY TEL. NO.:
PLEASE PROVIDE DETAILS OF ALL MEDICATIONS YOU ARE CURRENTLY TAKING,
AND THE HEALTH REASONS AS TO WHY SUCH MEDICATIONS ARE BEING TAKEN:
NAME OF MEDICATION HEALTH REASON FOR TAKING MEDICATION
PLEASE CONTINUE ON A SEPARATE SHEET SHOULD YOU HAVE NEED TO DO SO
Declaration
I, the undersigned, hereby declare that the information contained in this report is true and
accurate to the best of my knowledge.
I understand that if I knowingly or recklessly make a false statement or omit any material
particularly in giving information as part of this report I shall be committing an offence
and will be liable for prosecution.
I give my consent to the Licensing Authority to undertake checks of my records by way
of my G.P. / Doctor in order to promote the objective of upholding public safety.
I confirm I have read the General Data Protection Regulation 2016 (GDPR) / Data
Protection Act 2018 (DPA) - Privacy Notice and the Disclosure & Barring Services Privacy
Notice above.
Signature (Applicant): _______________________________ Date:____________________
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General Data Protection Regulation 2016 (GDPR) / Data Protection Act 2018
(DPA) - Privacy Notice.
Under the GDPR and DPA, Ashfield District Council, Urban Road, Kirkby in Ashfield,
Nottingham. NG17 8DA is a Data Controller for the information it holds about you. The
Council will hold the information above provided by you for assessing your application.
The lawful basis under which the Council uses personal data for this purpose is Public
Task.
The information provided by you includes the following special categories of personal
data:
Physical or Mental Health
Genetic / Biometric data
Criminal History (including motoring offences)
Information in these categories is used by the Council on the basis that such use is
necessary for reasons of substantial public interest, and in accordance with the provisions
of the Data Protection Act 2018.
Your data will be held for a period of 6 years. Subject to some legal exceptions, you have
the right to request a copy of the personal information the Council holds about you; to
have any inaccuracies corrected; to have your personal data erased; to place a restriction
on our processing of your data; to object to processing; and to request your data to be
ported (data portability). The information provided by you may also be used for other
functions carried out by the Council in accordance with GDPR and DPA. For more
information about how the Council may use your data and to learn more about your rights
please see the Council’s Privacy Statement: www.ashfield.gov.uk/privacy
If you have any concerns or questions about how your personal data is processed, please
contact the Council’s Data Protection Officer at the address at the bottom of this form or
by email to dpo@ashfield.gov.uk. If you are dissatisfied with the Council’s response you
can complain to the Information Commissioner's Office in writing to: Information
Commissioner's Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF or by
telephone 0303 123 1113 (local rate) or 01625 545 745.
If you have any concerns or questions about how your personal data is processed, please
contact the Council’s Data Protection Officer at the address at the bottom of this form or
by email to dpo@ashfield.gov.uk . If you are dissatisfied with the Council’s response you
can complain to the Information Commissioner's Office in writing to: Information
Commissioner's Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF or by
telephone 0303 123 1113 (local rate) or 01625 545 745.
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APPENDIX FOUR SELF-CERTIFICATION MEDICAL REPORT (Ashfield District Council)

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Completed 5 February 2021

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