We, as the registered provider, are responsible for having in place suitable vetting processes to safeguard children in our care. We have in place rigorous vetting and recruitment procedures that make sure that those who work for us or work or live on the premises where we provide daycare are suitable for both employment and to work or be in regular contact with young children. We take steps to ensure that our staff remain suitable for both employment and regular contact with children. If we have any concerns about your health, any medication that you are taking and any possible impact or risk to the children we will raise these concerns with you. It is our duty and responsibility to make sure you are fit and safe to work with children at all times. The information within this questionnaire will be kept confidential.

Health Questionnaire

Surname
First name(s)
Date of birth
Home address:
Telephone number:
Please tick as appropriate
Yes / No
1.  / Are you currently attending a doctor’s surgery or hospital for regular appointments?
If yes, please provide details
2.  / Have you had within the past five years any hospital admissions or outpatient treatment?
If yes, please provide details
3.  / Are you currently taking any medication or having any other treatment from a doctor, hospital or other medical practitioner?
If yes, please provide details


As an Early Years provider we must ensure that those practitioners only work directly with children if medical advice confirms that the medication is unlikely to impair that staff member’s ability to look after children properly. Staff medication on the premises must be securely stored, and out of reach of children, at all times.

If we believe this medication may affect your suitability to work with children we will need to clarify further information and carry out Risk Assessments

Do you suffer from any medical condition which significantly affects your:
Yes / No / If ‘yes’ please provide details
Sight?
Hearing?
Walking?
Ability to climb stairs?
Ability to bend?
Ability to lift?
Stamina?

In the past five years have you had any medical problems other than minor illnesses such as colds?

If yes please provide details and dates:

Dates / Details
Have you suffered from any of the following?
Please asterisk condition(s) still current. / Please tick as appropriate
Yes / No / Current
1.  / Depression, anxiety, stress-related illness, or other mental health problems, including self-harm and eating disorders
2.  / Blackouts, fits, epilepsy or faints
3.  / Heart problems
4.  / Diabetes
5.  / Breathing difficulties such as asthmas
6.  / Back, neck or other problems with arms, legs and joints
7.  / Alcohol or drug dependency or misuse

If ‘yes’ please provide details of the time you had off sick and the date(s) you received treatments:

Dates / Treatment / Time off sick

Have you been in contact with a significant infectious disease, such as tuberculosis, or hepatitis? Yes No

If yes, please give details and dates

Dates / Details
How many cigarettes do you smoke a day?
0
Fewer than 10
10-20
More than 20
What is your alcohol intake a week in units?
1 unit = 1 glass of wine or ½ pint of beer
Are relevant vaccinations up to date (eg tetanus, hepatitis)?
How many days sick leave have you taken from your employment in the past year?
Have you ever been retired or had your contract of employment terminated with a past employer due to ill health?
If yes, please provide details:

Statement of declaration and consent

I declare to the best of my knowledge the answers given to the questions above are full and correct. I understand that my employer may ask me to attend a further interview or consultation about my health and may require information from my doctor or a registered health professional regarding my wellbeing, health care or any prescribed medication that I am taking if this may affect my suitability to work with children. I give my employer permission to do this and agree to notify my employer of any significant changes to my health.

Signed: ______Date: ______

Medical Update / Changes to the above / Signed / Date

Z:\Early Years\Early Years Foundation Stage\Childcare Advisers Development Team\Useful information across team\Appraisal and supervision training\Health Questionnaire.doc