Staff Medication Form  (SMF)
This form is for staff to report any medication, prescribed or not, which they are taking, either as a one-off or ongoing. This should be completed EACH TIME you take one off medication. Advil, ibuprofen based medication and asthma medication are excluded. All other medication taken either on a one-off basis, or  as an ongoing or regular medication, must be reported.

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Email *
Your full name
Phone Number
Israeli ID number, or passport number
Type of medication *
Is the medication prescribed by a doctor? *
Name of medication being taken *
Reason for taking medication *
Any known side effects or reasons the medication could impair judgement at work (eg makes you sleepy) *
IF LONG TERM: How often is the medication taken, and in what dosage?
IF SHORT TERM: Date/Time of medication taken and dosage *
A copy of your responses will be emailed to the address you provided.
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