Occupational Health Assessment Form for
Social Work Training
CONFIDENTIAL FOR OCCUPATIONAL HEALTH USE ONLY /

Your answers to this questionnaire will be confidential to Occupational Health and will not be disclosed to anyone without your permission.

The purpose of this assessment is to help determine if you have any health problems, disabilities or learning differences which may affect your capability to fulfil the criteria required for social work training and practice. It involves consideration of the potential for duties to affect any existing health condition or disability you may have as well as such conditions on your ability to undertake social work training and practicesafely and effectively.

Please see the HCPCwebsite for further information on the requirements which you will need to meet

Before health clearance is given you may be contacted by Occupational Health for further informationon your condition or disability and you may need to be seen by an Occupational Health Advisor and/or Physician.

For the majority of students a simple Fit statement will be provided to the Centre for Lifelong Learning (CLL) team.Where a more detailed assessment has been completed by Occupational Health, in addition to the fitness statement, Occupational Health will write a report which will be sent, with your consent, to the Social work tutors only. The report will provide where appropriateanyrecommendations, adjustments or assistance Occupational Health advise to enable you to meet the criteriafor social work training and practice.

SURNAME / FORENAMES
DATE OF BIRTH / STUDENT NUMBER / MALE FEMALE
HOME ADDRESS
EMAIL:
HOME Tel:
MOBILE Tel:
  1. Do you have any illness, impairment, disability (physical or psychological) or learning difference which may affect your ability to undertake any aspect of the course,including social work practice?
If YES please give details below YES NO
  1. Have you ever had any illness, impairment or disability which may have been caused or made worse by work and could affect your ability to undertake any aspect of the course, including social work practice?
If YES please give details below YES NO
  1. Are you having, or waiting for, treatment (including medication) or investigations at presentwhich could affect your ability to undertake any aspect of the course, including social work practice? YES NO
If your answer is YES please provide details of the condition, treatment and dates below
  1. Do you think you may need any adjustments or assistance to help you to undertake your studies and social work practice duties safely and effectively?
If YES please give full details below YES NO
  1. The Equality Act makes it unlawful to knowingly discriminate against disabled persons in connection with employment. A person has a disability for the purposes of the law if they have a physical or mental impairment which has a substantial and long term adverse effect on their ability to carry out normal day-to-day activities.
This includes ‘hidden’ disabilities such as Diabetes and Epilepsy which may bewell controlled on treatment and therefore symptomless, but if left untreated would have a substantial and long-term adverse effect. It also includes progressive illnesses such as Cancer, HIV and Multiple Sclerosis, from the day of diagnosis onwards.
A "disabled person" means a person who has a disability as defined above. Long term means 12 months or more.
To comply with the law, the Centreneed to know if you consider yourself to have a disability.
Do you have a disability as defined above? YES NO
The Disability Services Teamencourage all applicants to declare any disability or learning difference and to contact themin advance of their course startingto discuss their support requirements during their studies.
Email:
Telephone number: 024 76150641
You can find additional information about the University of Warwick Wellbeing Support Services here
It is sometimes helpful for Occupational Health to be able to liaise with theDisability Services team to discuss your requirements. To allow us to do this we will need your permission to share relevant information with the Disability Services Team, please can you indicate below if you consent.
I DO /DO NOT consent to the details of my disability being discussed with the Disability Services Team
(please tick as appropriate)
Signed: ...... Date: ......

DECLARATION

I declare the answers to the above questions are true and complete to the best of my knowledge and belief.

Signed: ...... Date: ......

Please email your completed form to the University of Warwick Occupational Health Services Resource address at

NOTE: Occupational Health will use the email address you use to submit the health form to contact you if necessary so please use an email address which is confidential to you.

If you do not have access to a personal email, please return your completed form at the address below and make sure you include a telephone number so Occupational Health can contact you if necessary.

Occupational Health

University Safety & Occupational Health Services,

Westwood House,

Westwood,

The University of Warwick,

Coventry

CV4 7AL

For Occupational Health Use Only
Meets health requirementsfor social work practice / Meets health requirements with adjustments detailed below / Does not meet health requirements
for social work practice
Recommendations/Comments
Signed (Occupational Health Adviser/Physician) / Date

Page 1 of 3