New Starter Health Questionnaire

HR Sub Date*

Date

Full Name of New Starter*

Job Title*

Group Company Name*

Department*

Team Management*

Please read this information before completing this Questionnaire

This questionnaire should be completed by all new employees for following purposes:

To allow us assit to employees who may need further health assessment or advice.
To enable HR to give an opinion on your fitness for your role.
To be a simple record of your health status at the time you started employment and on an annual basis thereafter.

If you answer YES to any question, HR will contact you and they will conduct a short interview in person or over the phone to obtain further information. In certain cases, you may be asked to attend in person. They will then provide an opinion to the manager on your fitness for your role.

Failure to disclose a condition that you know might affect your work, could limit your rights in respect of the Equality Act, and adversely affect our ability to assit you by making reasonable adjustments to your role.

Function of the H&S Department

The H&S department will provide advice about making reasonable adjustments to your workplace, equipment or duties to help you start or continue employment.

Confidentiality of information

This declaration will be processed by the HR department. Please do not write any confidential medical history or information on this form as this can be discussed in person with HR. The information collected in that discussion will be treated as confidential personal information.

GDPR and Data Retention

Personal information collected on this form will be processed and stored in full accordance with GDPR and our privacy policies. The information collected will only be used for the stated purposes and will not be shared with any external agency, unless with your prior approval.

By completing this questionnaire, you give permission for the information collected to be stored by us for the duration of your employment, and for up to 3 months following the end of employment.

If you leave employment we will review whether we need to retain that information. We will delete any unnecessary information, subject to any other legal obligations we may have around retaining employment and health and safety records.

Equality Act (2010)

Under the Act, we have a duty to make reasonable adjustments to ensure you are not put at a substantial disadvantage by employment arrangements or any physical aspect of the workplace.

Disability Discrimination Act (1995)

Under the Act, a person has a disability where 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.

Health conditions we want to know about

You should declare a physical or mental health condition by answering “YES” if that condition:

has caused previous episodes of long-term sickness or absences from work of more than 20 days in the previous 12 months);
has caused previous repeated short-term sickness absences (more than 6 separate absences in the previous 12 months);
was caused by a previous employment;
is likely to cause future absences;
is likely to become progressively worse and is likely to be made worse by your new work;
is likely to prevent you from carrying out your contracted duties or prevent you using equipment necessary to do your job;
is likely to prevent you from working your contracted hours;
causes any difficulties with communication, such as hearing, speech or eyesight;
prevents you from operating the equipment necessary to do your job;
prevents you from using the Personal Protective Equipment needed for that job;
could put yourself or others at risk of injury;
affects your mood, memory, ability to learn or social skills; or
restricts your movement, strength or posture.

In addition, you should also tick the appropriate box below for any condition when:

You are taking medication where side effects may affect you at work; and
A doctor has warned you not to do particular types of work or other activities.

Please ensure that you have read the guidance notes before answering all of the questions.

Failure to answer all of the questions could delay the start of your employment.

	YES	NO
Do you have any confirmed medical, physical or mental health conditions that could affect your performance or could be made worse whilst carrying out your job role?
Have you had any physical or mental health condition that might affect your safety or the safety of others at work?
Do you have any long term health conditions or a disability which impact you on a day to day basis?
Do you need any adjustments made to your workplace, workplace equipment or working practices?
Do you have any allergies, ailments, injuries or conditions which could affect your performance during employment?
Are you taking any form of medication that could affect your working performance at this present time?
Do you have any scheduled medical appointments or procedures in the foreseeable future?
Do you have or have you had any abuse issues related to alcohol or drugs?
Do you use any legally banned substances for any social or physical recreation which could impact your ability to attend or perform at work?
Are you undergoing any current medical testing or investigations which could affect you working performance at this time?
Are you aware of any impending medical, physical or mental health investigations which could affect your working performance in the foreseeable future?
Do you have any medical condition which affects your ability to drive?
Do you wear glasses or have any visual impairment?
Do you use a hearing aid?
Do you have any issues in making yourself understood?

Declaration

I confirm that to the best of my knowledge, the answers given above are true and correct. I also confirm that I have read and understand the guidance notes before making the above declaration and understand that failure to disclose any relevant information could result in dismissal.

Signature *

Medical conditions?*

Please provide a medical conditions note:*

Disability?*

Please provide a disability note:*

Is an H&S review required?*

Please explain what type of review is required:*

Questionnaire Result?*

If the questionnaire result is anything other than Fit for the role with no restrictions, please explain what the next steps are:*

Please enter any other comments here

HR Reviewed completed by*

Signature*

HS008

Health Questionnaire

HR Questionnaire Review

H&S Review

HR Final Review