Confidential

Health Assessment Questionnaire (New Employee)

This health questionnaire is to be completed by all newly appointed employees prior to commencement of role. The purpose of the questionnaire is:

  • to determine whether any adjustments are required to assist you in fulfilling your role
  • to assess whether the role may affect your health and make recommendations to reduce this risk where necessary

To avoid unnecessary delay,it is important that you complete all the relevant sections of the questionnaire and provide any supporting documentation where necessary.

All the information provided in this questionnaire will be held in strictest confidence and retained by the Occupational Health Department, in accordance with the Data Protection Act (1998). Under no circumstances will the data on the questionnaire be disclosed to anyone outside Occupational Health without your informed consent. The completed questionnaire will be seen only by the Occupational Health team. Further assessment by the Occupational Health Practitioner (OHP) may be required by telephone or face to face.

An Occupational Health statement detailing your name, date of birth and recommendations for workplace adjustments where necessary will be sent to your manager. The nature of any health condition will not be disclosed to your manager. If you have any difficulties completing this questionnaire or have any queries, please contact the OH dept on 01274 234947 or 233738.

Section 1

Employee Details

Last name: / Forenames:
Date of birth:

Section 2a

Please state either Yes or NO. If yes, please give further details in section 2b

  1. Do you have any limitations when:
  2. Sitting
  3. Standing
  4. Moving & handling (includes lifting/carrying)
  5. Balance/coordination

  1. Do you have/have you had any health issues that have been caused by or made worse by work?

  1. Are you having, or waiting for any treatment or investigations by your GP/Consultant?

  1. Have you had/do you need any workplace adjustments to support you at work?

  1. Would you like to discuss your health, in strictest confidence, with an Occupational Health Practitioner, either by phone or in person? (if yes, please ensure you have provided contact details)

Section 2b– details of any ‘Yes’ responses in section 2a

Please provide full details.

Example
Number: 6
Description of health issue: chronic lower back pain
Dates: 2005 – ongoing
What workplace adjustments did you require? A chair with additional lumbar support.
Number:
Description of health issue:
Dates:
What workplace adjustments did you require?
Number:
Description of health issue:
Dates:
What workplace adjustments did you require?

Declaration by Candidate

I declare that all the information given above is true and correct to the best of my knowledge. I understand that failure to give relevant and accurate information may result in the Occupational Health Practitioner being unable to make any appropriate recommendations for workplace adjustments. I acknowledge and understand that I may be required to attend an Occupational Health assessment.
Name: (Print) / Date:
Signature:

Please return this form either by e-mail to or by post to Occupational Health, University of Bradford, K29 Richmond Building, Richmond Road, Bradford, BD7 1DP

Health Assessment Questionnaire (New Employee)