University of Sheffield

Staff Occupational Health Service

Medical in Confidence

Health Assessment Questionnaire for Night Workers

It is your right under the Working Time Regulations 1998 (amended 2003) to have regular health assessments whilst a night worker (those who regularly work at least 3 hours between 11pm and 6am). This questionnaire will be used to assess if you have any conditions which may affect your ability to do night work only. Medical details provided are confidential, butyour manager will be advised on whether you are fit / unfit to undertake night work.

Personal Details:

Mr / Mrs / Ms / Miss / Dr / Prof / Other (Please state / delete as applicable)

Surname: ______Forenames: ______

Address: ______

______

Postcode: ______Contact Details: ______

Department: ______Work Tel. No. ______

Post Held: ______Date Commenced Current Post: ______

______

Please answer all the questions by ticking the appropriate box. Please note that ticking ‘yes’ does not mean that you will not be fit for night work but that a further assessment by an Occupational Health Professional may be required.

Have you developed any health conditions since you last completed a night worker questionnaire (if applicable)? Yes / No
Have you had any sickness absence since you last completed a night worker questionnaire (if applicable)? Yes / No

If ‘yes’, please state number of days, number of occasions and reasons for absence:

1. Do you suffer from diabetes? / Yes / No
If ‘yes’ is it under control and your blood sugar stable?
Does it require treatment with insulin on a strict timetable?
2. Do you suffer with any heart disease / circulatory disorder?
If ‘yes’ does this affect your physical stamina in any way?
3. Do you suffer from any stomach or intestinal disorder?
4. Do you get frequent indigestion / heartburn?
5. Do you have any medical condition where the timing of meals is important or are you on a special diet?

Yes No

6. Do you suffer from any medical condition affecting your sleep or sleep disorders?
7. Do you have asthma, bronchitis or any chronic chest condition?
Is it well controlled?
Does your condition cause troublesome night-time symptoms?
8. Do you suffer a mental health condition (anxiety, depression etc)
9. Do you have any condition requiring medication at strict times?
10. Do you have any other medical condition / health factors / disability which may affect your ability to do night work?
11. Are you receiving any treatment or medication, (give details)
12. Have you previously worked night shifts?
13. Give details of your shift pattern

Additional Details:

DECLARATION

I confirm that all medical information given on this form is true and accurate to the best of my knowledge.

Signature: ______Date: ______

______

If you do not wish to complete this questionnaire please sign and date the declaration below and return to the Staff Occupational Health Service, Firth Court, Western Bank, SHEFFIELD S10 2TN.

------detach here

Declaration of Employee to Decline the Health Assessment Questionnaire for Night Workers

I understand that under the Working Time Regulations 1998, I am entitled to a night worker health assessment but wish to decline this offer.

Signature: ______Date: ______

Night/gaa/0409