The company has a duty to assess what hazards are present in your place of work and one way of doing this is to ask that employees complete a health surveillance form which relates to those hazards likely to be found. You are required to co-operate with measures that the employer takes to protect your health at work. In this respect you should complete this questionnaire as honestly and accurately as possible.
1. / How long have you worked at the company carrying out manual handling operations? / … / Years / … / Months2. / Have you received training in manual handling operations? / Yes / □ / No / □
3. / Do you suffer from back pain, which you believe is as a result of the manual handling operations that you carry out? / Yes / □ / No / □
If you have answered Yes, describe the manual handling operation(s) that you undertake which you believe is responsible for your back pain.
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4. / Do you suffer from pain, in either, your hands, arms, neck or shoulders, which you believe is as a result of the manual handling operations that you currently undertake?
If Yes, please state in which areas you suffer pain and give details of the manual handling operation, which you believe is responsible.
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5. / If you have ticked Yes at either question 3 or 4 above, have you informed your supervisor that it is your belief that it is the manual handling operation that is causing the pain?
If Yes, please state name of supervisor and date:
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6. / If you have ticked Yes at question 3 or 4 above, have you visited your GP?
If Yes, name of GP and date of visit:
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7. / If Yes to question 5 and 6 above, have you proposed any ideas to the supervisor or made any improvements yourself, or do you have any new ideas as to how the manual handling operation can be avoided or improved to make the task less difficult?
If Yes, what:
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Employee Name: / Employee Signature: / Date:
Manager Name: / Manager Signature: / Date:
Thank you for taking the time and trouble to complete this questionnaire.
All information will be treated as confidential.
Cope Safety Management Ltd : 0844 800 4266 www.jwcope.co.uk email:
CSM011/01