Health Placement Questionnaire - General

Health Placement Questionnaire

Strictly Confidential
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 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 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 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
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
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 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 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 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
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

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*

Clear
Date*

DayMonthYear
Date
Should be Empty: