Night Workers Health Questionnaire
Working time legislation requires that employers offer people who work at night the opportunity of a free health assessment before they start working nights and on a regular basis after that. This form is designed to meet that requirement and help us ensure that you remain healthy whilst working at night. It is based on advice issued by the Department for Business Innovation and Skills.The company will make an assessment of your initial or continuing suitability for night work based on the answers you give this questionnaire. Where we are uncertain we may ask you to attend an examination by qualified occupational health practitioner.
Branch Location
Please Select
Dover
Ashford
Thanet
Canterbury
Newton
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Please Select
Healthcare Assistant
Field Care Supervisor
Office Manager
Registered Manager
Care Co-Ordinator
GP Surgery
GP Surgery Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Surgery Telephone Number
How long have you worked night shifts?
Are you on permanent nights?
Yes
No
Are you diabetic?
Yes
No
If yes do you require insulin injections?
Yes
No
Are you diagnosed with a heart condition or circulatory (blood, artery or vein) disorder?
Yes
No
If yes does this affect your physical stamina and your ability to do physical work?
Yes
No
Do you require the specific timing of a meal for medical reasons?
Yes
No
Do you have a medical condition which affects your sleep?
Yes
No
Are you diagnosed with a Chronic chest disorder (such as asthma) where night-time symptoms are particularly troublesome?
Yes
No
Have you currently or in the past been diagnosed with depression, stress, nervous disorders or other mental health illness, alcohol or drug addiction in the last two years?
Yes
No
Are you aware of any other health factors that may affect your fitness to carry out night work or do you feel night shifts affect your health in any way?
Yes
No
Please use the space below for any additional comments, particularly where you have answered YES to a question.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: