Step 1 of 5 20% Candidate code cannot be confirmed or has expired or been cancelled- Please contact the person who issued the code to you.This questionnaire will be CONFIDENTIAL to the Health Assured Occupational Health Team. The purpose of the questionnaire is to see whether you have any health conditions or disabilities that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. If further clarification or information is needed you may be contacted by the Health Assured team and may need to be either spoken to by phone, or seen by an Occupational Health Nurse or Doctor. We are an Equal Opportunities employer and applicants with disabilities are encouraged to apply for jobs. Employee DetailsName * REQUIRED First Last Date of Birth - must be dd/mm/yyyy format * REQUIRED DD slash MM slash YYYY Gender * REQUIRED Male Female Non-binary Prefer not to say Job Title * REQUIRED Department * REQUIRED Manager Contact 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 companyHave you worked for the company/organisation before? * REQUIRED Yes No Please tick the appropriate box below and provide details if neededDo you have any illness/impairment/disability (physical or psychological) which may affect your work? * REQUIRED Yes No Additional Comments * REQUIREDHave you ever had any illness/impairment/disability which may have been caused or made worse by your work? * REQUIRED Yes No Additional Comments * REQUIREDAre you having any treatment/medication that could affect your ability to work? * REQUIRED Yes No Additional Comments * REQUIREDDo you think you may need any adjustments or assistance to help you to do the job? * REQUIRED Yes No Additional Comments * REQUIRED Food Handling Pre-Placement Screening QuestionsThis section of the questionnaire is to ensure all staff handling food and working in a food handling area are fit to work with or around open food. If the answer to any of the following questions is YES then you may be contacted by Health Assured Team to be seen or phoned by a Doctor or Nurse. Have you now or over the last 7 days suffered from diarrhoea and/or vomiting? * REQUIRED Yes No Additional Comments * REQUIREDStomach pain, nausea or fever? * REQUIRED Yes No Additional Comments * REQUIREDAt present are you suffering from any of the following;Skin infections of the hands, arms or face? * REQUIRED Yes No Additional Comments * REQUIREDBoils/styles/septic fingers? * REQUIRED Yes No Additional Comments * REQUIREDAny disease or discharge from eye/ear/gums/mouth? * REQUIRED Yes No Additional Comments * REQUIREDRecurring skin or ear trouble? * REQUIRED Yes No Additional Comments * REQUIREDA recurring bowel disorder? * REQUIRED Yes No Additional Comments * REQUIREDJaundice? * REQUIRED Yes No Additional Comments * REQUIREDAny open wounds or grazes? * REQUIRED Yes No Additional Comments * REQUIREDDo you have any disease or infection that can be transmitted via bodily fluids? * REQUIRED Yes No Additional Comments * REQUIREDHave you ever had or are known to be a carrier of typhoid or paratyphoid fever? * REQUIRED Yes No Additional Comments * REQUIREDAre you known to be a carrier of Salmonella Typhi or Paratyphi? * REQUIRED Yes No Additional Comments * REQUIREDAre you a carrier of any type of Salmonella? * REQUIRED Yes No Additional Comments * REQUIREDIn the last 21 days have you been in contact with anyone at home or abroad who may have been suffering from typhoid or paratyphoid? * REQUIRED Yes No Additional Comments * REQUIREDDo you suffer, or have you suffered in the past from any allergic condition with food ingredients, e.g. flour, fish, eggs, nuts, soya, milk etc.? * REQUIRED Yes No Additional Comments * REQUIREDCountries visited in the last 6 weeks: please specify: DeclarationI 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 Work Health Assessment, Health Assured will discuss the recommendations with me before making them available to my employer. I agree to my information being stored and processed by Health Assured Occupational Health staff in a confidential manner according to the Data Protection Act. If you wish to access your records please request a Data Subject Access Request by contacting us. There may be a small administration charge for this.Please enter name as a signature * REQUIRED Date - must be dd/mm/yyyy format * REQUIRED DD slash MM slash YYYY
