Please fill out this form in preparation of your supervision meeting at least 3 days prior to your meeting. Thank you. Your DetailsName *Date *Have any of your contact details changed in the last 6 months? *YesNoHave any of you emergency contact's details changed in the last 6 months? *YesNoWork life balance *Annual leave, work load, attendance, well being, sickness, punctuality etc. How are you finding this? Is your rota working for you? Are you happy with your role and responsibilities? The NurseryDo you have any safeguarding concerns? *Any concerns about children? Our procedures? Staff? Anything else that you wish to share with us?YesNoIf yes, please give details Do you have any health and safety concerns? *Is anything unsafe or dangerous? Are there any maintenance issues?YesNoIf yes, please give details Equalities and Diversity *What do you do well to support policy? Do you need support? Do we need changes to the menu? (Think about festivals, cultures, religions, English as second Language, etc)SEND - Special Educational Needs and Disabilities *Any behaviour support, concerns, achievements, gifted and talented? Do you need any support? Do we require any resources? Do you feel you could support children with SEND?Any Messages to Management? Your RoleStaff Practice - EYFS statutory requirements/safer food better business *Working practice of yourself, kitchen team and wider team, review your knowledge of policies and procedures and legislation. Are you meeting the requirements of your job? (ask for copy of job description if necessary) Review your environments inside and outside and are you using them effectively? (Think about records, communication, allergens, inspections, compliance, law etc.)Recent successes and progress *What has been your biggest achievement recently/proud of do best? Review your targets from last meeting - have you achieved them and how?Areas to improve *What has not gone so well? Are there any problems? Do you need help with anything? What has been your biggest challenge?Support *Is there anything else that we can do to support or assist you with your role?Anything else that you would like to share with us? Personal Targets What targets are you working towards?1 *2 *3 * Questionnaire On a scale of 1 to 10, 1 being the lowest and 10 being the highest, please rate the following:Happiness at work 12345678910Feeling valued/having a voice 12345678910Relationships with your colleagues 12345678910Partnerships with parents 12345678910Equipment in the kitchen 12345678910Environment inside/outside 12345678910Support from Management Team 12345678910Continued Professional Development opportunities 12345678910Personal workload, paperwork, admin, Famly posts etc. 12345678910Cleanliness and tidiness of the setting 12345678910Knowledge of EYFS, safer food better business, policies and legislation 12345678910Conduct (dress code, punctuality and attendance) 12345678910Would you like to commend a colleague for something special or because they make work a nicer place to be for you? Health Declaration Please complete your health declaration fully. If you fail to declare significant information about your health, we may judge that you are not suitable to care for children and/or young people.Doctor's Name (if different from registration)Phone Number Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryHospital or other healthcare professional name (If applicable)Phone Number Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountry1. Are you taking any medication? *YesNoIf YES, what is it called, what is it for and what dose are you taking (see box or bottle label)? How long have you been taking it? 2. Are you receiving any other treatment, like physiotherapy, counselling, acupuncture? *YesNoIf YES, what and for how long? 3. Are you waiting for any other treatment like those mentioned in 2, or surgery? *YesNoIf YES, please provide details 4. Have you received any treatment, like those mentioned in question 2, in the past 5 years? *YesNoIf YES, please provide details 5. Do you have any medical condition that: Affects your physical ability i.e. stamina, walking, balance, bending, kneeling, lifting a child? *YesNoIf Yes, please provide details May impair your consciousness, make you black out, lose concentration or become confused or disoriented? YesNoIf Yes, please provide details Affects your hearing in any way (after correction with any device)? *YesNoIf Yes, please provide details Affects your eyesight in any way (after any lens correction)? *YesNoIf Yes, please provide details Causes depression, anxiety, panic attacks, mood swings, anger etc.? *YesNoIf Yes, please provide details Causes severe pain? *YesNoIf Yes, please provide details Causes excessive drowsiness? *YesNoIf Yes, please provide details Affects you in any other way? *YesNoIf Yes, please provide details 6. Have you been investigated or treated for any of the above, in the past five years? *YesNoIf yes, please provide details 7. In the past five years have you had any medical problems other than minor illness such as colds? *YesNoIf YES, please provide dates and details 8. In the past five years have any hospital admissions or outpatient treatment? *YesNoIf YES, please provide dates and details 9. Are you suffering from or have you ever suffered from any of the following? A) Depression, anxiety, stress-related illness or other mental health problems, including self-harm and eating disorders *YesNoB) Blackouts, fits, epilepsy or faints *YesNoC) Heart Problems *YesNoD) Diabetes *YesNoE) Breathing difficulties such as asthma *YesNoF) Problems with back, neck, arms, legs or joints *YesNoG) Alcohol or drug dependency or misuse *YesNoPlease indicate with the letter of any conditions that are still current If you have answered YES to any of the above conditions, please provide details of any date(s) you received treatment and the length of time you were on sick leave.Date Treatment Time on Sick Leave A) B) C) D) E) F) G) Have you ever suffered from or been in contact with a significant infectious disease such as tuberculosis, hepatitis or covid-19? *YesNoIf YES, please provide dates and details Suitability Declaration Please answer the questions below to demonstrate that you are safe to work with children. If there are any aspects of the declaration that you are not able to meet, you should disclose this immediately to the manager/senior responsible for your recruitment.Have you been cautioned, subject to a court order, bound over, received a reprimand or warning or found guilty of committing any offence since the date of your most recent enhanced DBS/PVG disclosure? *YesNoHave you been cautioned, subject to a court order, bound over, received a reprimand or warning or found guilty of committing any offence either before or during your employment at this setting? *YesNoHave you ever lived or worked abroad? *YesNoAre you ‘Disqualified for Caring for Children’? *YesNoHave you committed any offences against a child? *YesNoHave you committed any offences against an adult (e.g. rape, murder, indecent assault, actual bodily harm etc.)? *YesNoHave you been barred from working with children (DBS/PVG)? *YesNoAre you living with someone who has been barred from working with children (DBS/PVG)? *YesNoAre you living in the same household as someone who has been disqualified from working with children under the Childcare Act 2006? *YesNoHave your own children been taken into care? *YesNoHave/are your own children the subject of a child protection order? *YesNoHas your name been placed on the DBS/PVG barring list? *YesNo VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: