PARKING PERMITS 2016/17 – CONFIDENTIAL

OCCUPATIONAL HEALTH ASSESSMENT FORM
The purpose of this questionnaire is to establish the level of need to park at University sites.
Your employer will be notified whether you need to park close to work or not. Following submission of this questionnaire direct to York NHS Trust Occupational Health Services, the occupational health team will undertake an independent assessment that may involve contacting you for further information or writing to your GP/Specialist for further medical information.

Confidentiality: All information provided by you in completing this questionnaire will be treated in the strictest confidence by Occupational Health. Please answer all the questions fully and accurately.

Disability Discrimination Act 1995/2005: The Occupational Health Service operates and advises in accordance with this Act and other legislation including The Health and Safety at Work Act (1974).

When completed, return this form to: OCCUPATIONAL HEALTH SERVICES, Centurion House, Centurion Park, Tribune Way, Clifton Moor, YORK, YO30 4RY. To ensure confidentiality, please DO NOT return it to Reception with your permit application.

PERSONAL DETAILS & HEALTH QUESTIONNAIRE

Surname

/

Title Mr, Mrs, etc.

First name(s) / Maiden name
Job title / Sex (M / F)
Your address and postcode / Date of Birth
Home Phone No.
Mobile Phone No.
GP address and postcode / Work Phone No.
Can we contact you at work if necessary?
Please circle: Yes No

TO BE COMPLETED BY THE OCCUPATIONAL HEALTH SERVICE:

Outcome of Health Assessment

✔

1. Occupational Health support given for parking provision at the place of work
2. Occupational Health support NOT given for parking provision at or near place or work.
3. One to one assessment requested.
OH Clinician Name (Print): / Signed: / Position: / Date:

Please complete the following questions in full.

Do you have any of the following: /

Yes

/

No

1. A post-viral fatigue or chronic fatigue syndrome, for example, M.E.?
2. Heart/circulatory trouble or raised blood pressure?
3. Asthma, bronchitis, or any other chest problems?
4. Diabetes, thyroid or other hormone problems?
5. Any musculo-skeletal problems i.e. back, neck or joint problems?
6. Difficulty walking, or a condition that affects mobility?
7. Any other condition which you feel requires you to park close to your place of work?
8. Do you walk around the University campus as part of your job?
9. Do you have a blue badge for disabled parking?

If answering yes to any of the above questions please provide details below. Continue on a separate sheet if necessary.

DETAILS OF MEDICAL CONDITIONS

Please give more details of your medical condition including what it is, when it was diagnosed, how if affects your physical activity and any other affects on your day-to-day activities.
How far are you able to walk comfortably? Do you use any walking/mobility aids? If yes, what?
Is the condition temporary or permanent?
If temporary, what is the prognosis for recovery?
How is your condition being managed by your GP/Specialist/Other Healthcare Professional?
Have you been given any specific medical advice regarding level of activity you should undertake?
Are you taking any tablets, medicines, injections or ointments regularly?
If yes, please state type and dose:

DECLARATION:

I declare that the information I have given on this form is true to the best of my knowledge and belief. I understand that a submission of inaccurate information relating to my health may result in disciplinary action being taken. I am willing to undergo a medical examination.

Signed: ……………………………………………………….Date: ………………………….