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.

Your Company/Organisation: unknown company

I 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 * REQUIRED
• Date - must be dd/mm/yyyy format * REQUIRED
  DD slash MM slash YYYY