Step 1 of 3 33% Your employer has requested that you have the opportunity of having a medical assessment of your fitness to work nightshifts. There is a legal requirement under the Working Time Regulations that you are offered a free health assessment by your employer. The purpose of this questionnaire is to gain information in order that we can assess and offer an opinion on your fitness for nightshift work. Following your assessment, an occupational health report/certificate will be sent to your employer. Advice given in the report will be expressed in terms of fitness to work rather than personal medical information.Candidate code cannot be confirmed or has expired or been cancelled- Please contact the person who issued the code to you.Employee DetailsName * REQUIRED First Last Date of Birth - must be dd/mm/yyyy format * REQUIRED Date Format: DD slash MM slash YYYY Job Title * REQUIREDContact Tel: * REQUIREDEmail * REQUIRED Home Address * REQUIRED Street Address Address Line 2 City Region Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your Company/Organisation: unknown company Do you suffer from any of the following?Diabetes? * REQUIREDYesNoHeart or circulatory problems? * REQUIREDYesNoStomach or bowel disorder? * REQUIREDYesNoChronic chest condition especially if night-time symptoms are a problem? * REQUIREDYesNoSeizures or epilepsy? * REQUIREDYesNoAny medical condition which required very strict timings for medication? * REQUIREDYesNoAny medical condition that causes difficulty sleeping? * REQUIREDYesNoAny medical condition that could be worsened by night working? * REQUIREDYesNoDo you have any health concerns regarding working at night that you would like to speak to an occupational health nurse/advisor about? * REQUIREDYesNo DeclarationI confirm that: I agree to the assessment and agree that the results (in terms of fitness to work nightshift rather than medical details) can be given to my employer. I agree to an Occupational Health Advisor/Nurse contacting me about my question answers above if it is required. I declare to the best of my knowledge and belief that the information provided above is true and correct and that I have not knowingly withheld any information about my health. My personal medical information can be stored and processed confidentially by Health Assured Ltd, as per the requirements of the Data Protection Act. Please enter name as a signature * REQUIREDDate - must be dd/mm/yyyy format * REQUIRED Date Format: DD slash MM slash YYYY
