HD1

WORK HEALTH ASSESSMENT QUESTIONNAIRE

The information contained within this form will be used to allow the Occupational Health Service to advise the recruiting Manager about your fitness for the post you have applied for. This also includes any adjustments that may be required because of ill health or disability. It will also allow us to put into place any health checks that are required under health and safety legislation. If further details are required, you may be contacted by telephone or letter or asked to attend an appointment with an occupational health nurse / doctor.

Please complete both sides of the form fully, using a black pen, seal the form in the envelope provided and sign across the seal. You will only need to return this to the recruiting manager if a conditional offer of employment is made.

Surname: / Title: / Mr Mrs Ms
First Name(s): / M / F (circle)
Previous surname(s): / Date of Birth
Home Address: / National Ins No. /
Work Tel No:
Home Tel No:
Postcode: / Mobile No:
E-mail address:
Where can we contact you? Work Home Mobile
What job have you applied for? / Where is the job based?
Full time Term time Relief Part time
Casual / Length of contract?
Hours to be worked?

Please give list of jobs, voluntary work or full time education for the last five years including your current post.

Job Title / Employer: / Date from: / Date to:

PLEASE CONTINUE ON NEXT PAGE

Please answer the following questions, continuing on a separate sheet if necessary.
  1. Do you have any physical or mental health conditions or long-standing impairmente.g. hearing or visual impairments that affects your normal day-to-day activities? If yes please give full details here, including what the problem is, and when it began?
/ Yes No
  1. Do you need any special aids or adaptations to assist you at work, whether or not you have a disability? If yes please give full details here.
/ Yes No
  1. Are you currently having / waiting for any medical treatment or investigations of any kind? If yes please give full details here.
/ Yes No
  1. Have you any other health problems that we would need to know about in order to help you at work? If yes please give full details here.
/ Yes No
  1. Do you have any changes to your health which have been caused by work, eg: noise induced deafness, occupational asthma, hand-arm vibration syndrome, occupational dermatitis? If yes please give details here.
/ Yes No

I declare that to the best of my knowledge and belief the above responses are true and complete. I consent to a clinical assessment if required.

I understand that an opinion on my fitness to work including disability notification and advice on health and safety risk assessments will be sent to the relevant appointing manger based on this information. No confidential or personal health information will be released without my written permission. I understand that if I withhold information or give incorrect or misleading answers my employment may be at risk.

I consent to SheffieldCity Council recording and processing data on this questionnaire in accordance with its duties under the Data Protection Act.

Your Signature:

/

Date:

FOR OCCUPATIONAL HEALTH SERVICE USE ONLY:

Based on the information given on this form the above named is:

fit for the proposed post without restriction

fit for the post but may need some reasonable adjustments to be made (see separate report)

is not recommended for this post (see separate report)

Signed:S/OHNDate: