Health Placement Questionnaire

Your health, safety and welfare are important to us during your time working with GEM Partnership Ltd. Due to new legislation, we need to be aware if any of the following medical factors are relevant to you. This should not affect your assignment with the company but will allow us to consider any appropriate assessment and/or reasonable adjustments you may require.

Name*

First NameLast Name

Date of Birth*

DayMonthYear

Health and Disability

Do you regard yourself as disabled or as having a disability?*

YesNo

If you responded 'Yes' please give details below*

Do you require reasonable adjustments in order to perform the position you have applied for?*

YesNo

If you responded 'Yes' please give details below*

Do you suffer from any medical condition, that you would need support with in order to carry out functions which are essential to the position applied for?*

YesNo

If you responded 'Yes' please give details below

Are you currently receiving any treatment or investigations for any condition that you will need support with in order to carry out functions which are essential to the position applied for?*

YesNo

If you responded 'Yes' please give details below

Have you had any sickness absence from work or education in the past 2 years? Or any underlying or reoccurring health problem that has affected your ability to attend work regularly in the last 2 years?*

YesNo

If you responded 'Yes' please give details below

Do you have any problems that limit your ability to read or write?*

YesNo

If you responded 'Yes' please give details below

Do you have or are you currently being investigated for a learning difficulty, i.e. dyslexia, dyspraxia, ADHD?*

YesNo

If you responded 'Yes' please give details below

Drugs and Alcohol

Are you taking any medication which makes you drowsy or has any other side effects?*

YesNo

If you responded 'Yes' please give details below

Do you have a drug and/or alcohol dependency?*

YesNo

If you responded 'Yes' please give details below

Have you been treated for alcohol related problems or advised to reduce your alcohol intake in the last 12 months?*

YesNo

If you responded 'Yes' please give details below*

Have you used any drugs (not tobacco) within the last 12 months?*

YesNo

If you responded 'Yes' please give details below

Have you been treated for drug related problems within the last 12 months?*

YesNo

If you responded 'Yes' please give details below

I am aware of the Drug & Alcohol Policy and understand that as a condition of my working for GEM Partnership Ltd that I may be subject to drug and alcohol testing in line with the current policy.*

Agree

Vision and Hearing

Do you have any visual deficits that are not corrected with glasses/contact lenses?*

YesNo

If you responded 'Yes' please give details below

Have you been diagnosed as having a colour deficit (colour blind)?*

YesNo

If you responded 'Yes' please give details below

Do you have any visual deficits that would impact on any intrinsic functions of your role?*

YesNo

If you responded 'Yes' please give details below*

Do you have a hearing deficit?*

YesNo

If you responded 'Yes' please give details below

Has previous noise exposure contributed to your hearing deficit?*

YesNo

If you responded 'Yes' please give details below

Have you ever been advised to reduce noise exposure?*

YesNo

If you responded 'Yes' please give details below*

Skin Conditions

Do you suffer from any skin conditions that may be exacerbated by your environment, contact with substances or chemicals?*

YesNo

If you responded 'Yes' please give details below

Do you require any medical support with regard to a skin condition?*

YesNo

If you responded 'Yes' please give details below

General Health

Do you suffer from any respiratory conditions that may be exacerbated by your potential environment, contact with substances or chemicals?*

YesNo

If you responded 'Yes' please give details below

Do you require any medical support with regard to a respiratory condition?*

YesNo

If you responded 'Yes' please give details below*

Do you have any allergies?*

YesNo

If you responded 'Yes' please give details below

Do you suffer from any condition that causes you to have balance problems or would pose a safety risk to any intrinsic function of your role?*

YesNo

If you responded 'Yes' please give details below

Do you suffer from any condition that causes you to lose consciousness?*

YesNo

If you responded 'Yes' please give details below*

Do you suffer from blackouts, epilepsy or any condition that would pose a safety risk to either yourself, colleagues or the general public?*

YesNo

If you responded 'Yes' please give details below

Do you have any restriction on driving impose by the DVLA?*

YesNo

If you responded 'Yes' please give details below*

Do you presently suffer from any psychological condition including depression, anxiety, panic attacks or other stress related illness, requiring medication or other forms of treatment?*

YesNo

If you responded 'Yes' please give details below

Do you have any medical conditions that affect your muscles, ligaments or joints?*

YesNo

If you responded 'Yes' please give details below

Do you have any health problem or medical condition that would reduce your ability to stand or to move around your place of work throughout a normal working day, or carry things whilst working?*

YesNo

If you responded 'Yes' please give details below

Do you have any active implanted medical devices (AIMDs) such as a pacemaker, cochlea implant etc.?*

YesNo

If you responded 'Yes' please give details below

Do you have any passive implanted medical devices (PIMDs) such as metallic pins/joints etc.?*

YesNo

If you responded 'Yes' please give details below

Do you have any body-warn medical devices (BWMDs) such as hearing aids, insulin pumps etc.?*

YesNo

If you responded 'Yes' please give details below

From your knowledge of the job that you will be doing, is there anything that may impact on your health problem or medical condition?*

YesNo

If you responded 'Yes' please give details below

Are there any adjustments that you would require to allow you to undertake your role without impacting on your health problem or medical condition?*

YesNo

If you responded 'Yes' please give details below*

Are there any other factors that would impact on your ability to undertake your potential role?*

YesNo

If you responded 'Yes' please give details below*

NIGHT WORKERS ONLY

Under the Working Time Regulations employers must offer employees who work at night a regular health assessment. The aim of this assessment is to protect night workers by identifying any conditions that might mean that working at night poses a potential risk to their health and safety, a review by an occupational health professional can then advise employers how to adjust your work and/or work environment if needed.

Are you a night worker? If so, please read and complete the section below.*

YesNo

Please answer the following questions*

	Yes	No	If you responded YES please give details
Do you suffer from any sleep disorders?
Do you have any health issues that might prevent you from working at night?
Do you have a condition where the timing of meals is particularly important?
Do you have a medical condition that requires you to take regular medication at strict times?
Have you ever stopped working or been advised for medical reasons to not work at night?
Do you have any other medical conditions that may be worsened by night work, or affect your suitability to work at night?

I declare to the best of my knowledge I have answered all the questions above honestly and accurately.

I accept that the answers I have given will be relied upon and that any innacurate or dishonest answers I have given may affect my continued employment.

If I am asked to do so, I agree to discuss my answers and my fitness for work in medical confidence with an Occupational Health professional (either by telephone or face to face), so that professional advice about my fitness for work in this role can be obtained. I understand this would lead to a written report about my capability for this role, but no medical details would be revealed without my consent. This information may be shared with the Health and Safety Manager.

Signature*

Date*

Date