HMH Occupational Health Assessment Form

HMH Occupational Health Assessment Form
Guidance for completing the Occupational Health Assessment Form

The purpose of the questionnaire is to determine whether you have health problems that could affect your ability to undertake the duties of the post you have been offered or place you at risk in the workplace. It may be that adjustments or assistance is recommended as a result of this assessment to enable you to do the job. Our aim is to promote and maintain the health of all people at work. Before clearance is given for employment you may be contacted by the Occupational Health team and may need to be seen by an Occupational Health clinician.

Your answers to this questionnaire will be confidential. They will only be available to Occupational Health staff and will not be disclosed to anyone else without your implicit consent.

We do use anonymised information for audit purposes but will not reveal confidential information in any audit report. Specific guidance about the declaration form is given below.

IF YOU KNOWINGLY MAKE A FALSE STATEMENT OR CONCEAL ANY INFORMATION REGARDING YOUR MEDICAL HISTORY, YOU WILL BE LIABLE TO HAVE YOUR OFFER OF EMPLOYMENT/EMPLOYMENT TERMINATED.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Proposed Job Title

Do you have any of the following?

	Yes	No
A cough which has lasted more than 3 weeks
Unexplained weight loss?
Unexplained fever?
Have you had tuberculosis (TB) or been in recent contact with open TB?

If yes, please give details below
Do you have any health condition or disability which might impair your ability to undertake effectively the duties of the position which you have applied for?
Do you have a health condition or disability which might affect your work and might require special adjustments to your work or work environment?
If you answered yes to either of the above, please provide details below:
Do you have any illness/impairment/disability (physical or psychological) which may impact on your ability to undertake the role that you have applied for?
If yes, please give details below
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?
If yes, please give details below
Are you having, or waiting for treatment (including medication) or investigations at present that may impact on your ability to undertake the role that you have applied for? If your answer is yes, please provide further details of the condition, treatment and dates.
If yes, please give details below
Do you think you may need any adjustments or adaptations to the workplace or job role to help you undertake the role that you have applied for?
If yes, please give details below

Question

	Yes	No
Have you ever tested POSITIVE for HIV/AIDS?
Have you ever had or tested POSITIVE for Hepatitis B?
Have you ever had or tested POSITIVE for Hepatitis C?
Have you lived outside Nigeria within the last 5 years?

Are you up to date with immunisation/vaccinations for:

	Yes	No
Hepatitis B
Measles, Mumps and Rubella
Tuberculosis

DECLARATION
I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I understand that if any recommendations to my employer are necessary as a result of this occupational health assessment, the Occupational Health advisor will make recommendations to my employer.
Signature

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Name

First NameLast Name
Date

MonthDayYear
Date
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