New Employment Questionnaire

1

Will the applicant be involved in the following: (please tick appropriate boxes)

YES SOME NO

Standing…………………………………………………………………………….

Walking……………………………………………………………………………..

Climbing…………………………………………………………………………….

Working in confined spaces………………………………………………………

Vocational driving………………………………………………………………….

Driving fork lift trucks………………………………………………………………

Driving LGV/PCVs…………………………………………………………………

Working with chemicals…………………………………………………………..

Working with biological agents…………………………………………………..

Working with skin irritants/sensitisers……………………………………………

Working with dangerous machinery……………………………………………..

Exposure to hazards to unborn child/pregnancy………………………………

Exposure to night/shift work……………………………………………………..

Exposure to significant work place stress……………………………………….

Working with dust or fumes ………………………………………………………

Lifting or carrying heavy items……………………………………………………

Handling food………………………………………………………………………

Computer work/Display Screen Equipment…………………………………….

Prolonged sitting……………………………………………………………………

Occasional overseas travel……………………………………………………….

Outside work………………………………………………………………………..

Noise hazard area…………………………………………………………………

Other, please state ………………………………………………………………..

2

Previous Employment

(For completion by applicant)

General Health

(For completion by applicant)

YES NO

Are you currently in good health?…………………………………………

Did you take time off for sickness in the last two years, If so how many days?

/

…………………..days

Do you smoke? If so, how many a day?………………………………….

/

……………….per day

Do you drink alcohol? If so, how many units per week?………………..

/

………units per week

(N.B. 1 pint = 2 units, 1 spirit measure = 1 unit, 1 glass of wine = 1 unit)

(Please tick appropriate boxes, if yes is answered to any of the questions, please give details of the treatment and medications in the General Health Comments box below)

YES NO

Have you ever left or been denied, a job on health grounds?……………………………….

Have you ever been denied a driving licence on health grounds?……………………......

Do you consider yourself to be disabled? If so, please give details separately...... …….

Have you any disabilities affecting standing/walking/lifting/seeing/hearing/speaking/

driving/stair climbing or the use of your hands …………………………………………......

Are you attending an out patients clinic, or are you on a hospital waiting list?………………

Have you ever been treated for abuse of alcohol or any other addictive substance addictive substance?…………………………...

Are there any medical conditions that seem to run in the family?……………………………..

Have you experienced any problems from using display screen equipment?……………….

Have you ever experienced any problems in confined spaces / using lifts?…………………

Have you had any illness or accident that has required admission to hospital or clinic?…...

Have you ever had any major operations?……………………………………………………….

Are you receiving any treatment from your doctor? (if so describe below)…………………...

Have you been advised that you are unfit for night work or shift work?………………………

Specific Conditions

(For completion by applicant)

(Please tick appropriate boxes, if yes is answered to any of the questions, please give details in the Specific Conditions Comments box below.)

Are you suffering from, or have you ever suffered from, any of the following:

YES / NO / YES / NO
Heart disease of any kind / Mental health problems (incl. Stress, anxiety etc)
High blood pressure / Depression
Varicose Veins / Any musculo-skeletal problems
Asthma, bronchitis, or pneumonia / Eye disease or infection
Tuberculosis / Visual disability (not corrected by glasses)
Frequent diarrhoea or constipation / Hearing disability (not corrected by hearing aid)
Stomach or bowel disorders / Deafness or ear disease
Jaundice, gall bladder or liver disease / Skin disease, eczema, psoriasis
Hernia / Allergic conditions
Kidney disease or stones / Diabetes or thyroid disorders
Tropical disease / Blood disorder, anaemia, or haemophilia
Back pain or disorder / Any form of cancer
Neck pain or disorder / Any condition requiring surgery
Rheumatism or arthritis / Any work related medical condition
Epilepsy or flicker epilepsy / Bladder problems
Neurological conditions (incl. migraines) / Irregular or painful periods (females)
Prostate or testicular problems (males) / Blood borne virus
Dyslexia / Specific learning difficulties

Because of the responsibilities of your employer under the EC Directive on Pregnant Workers (92/85/EEC), you are advised if you are pregnant, to inform us in confidence, in order that you may be advised regarding protection from any physical, chemical or biological hazards in the work space.

3

Use this area to give details from previous questions and to give details of any other health conditions that you are suffering from, or have suffered from in the past.

If it is necessary for you to have a pre-employment medical please highlight below any dates you cannot attend

………………………………………………………………………………………………………………………………………………….

PLEASE READ THIS STATEMENT CAREFULLY BEFORE SIGNING

  1. I declare that all the foregoing statements are true to the best of my knowledge. I accept that in the event of my being employed and it is subsequently shown that medical information has not been disclosed by me, or has been misleading or false, the employer may terminate my employment.
  1. I understand that I may be required to attend a medical consultation/undergo a physical examination.
  1. I understand that although this form will be treated in medical confidence, further medical information may be requested from my doctor if considered necessary. (Subject to obtaining further consent under the Access to Medical Records Act.)
  1. I givethe Occupational Health Service of Liverpool City Council my consent to (a) hold relevant medical information to process my job application; (b) computerise my personal and medical information; (c) contact me to arrange appointments and manage my case; including linking my medical history to sickness absence data; and (d) use my medical information to prepare an assessment of my fitness for work for my prospective employer.
  1. I understand that the Occupational Health Serviceof Liverpool City Council will hold my information securely and give me access to my medical information, should I request it in writing.

Please return this form directly to:

Occupational Health Service,

Liverpool City Council,

Municipal Offices

Lower Ground Floor

Room 42A Dale Street

L2 2DH

Email address: