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  • 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 Details

  • Name * REQUIRED
  • Date Format: DD slash MM slash YYYY
  • Gender * REQUIRED
  • Home Address * REQUIRED

  • Your Company/Organisation: unknown company

  • Have you worked for the company/organisation before? * REQUIRED

  • Please tick the appropriate box below and provide details if needed

  • Do you have any illness/impairment/disability (physical or psychological) which may affect your work? * REQUIRED
  • Have you ever had any illness/impairment/disability which may have been caused or made worse by your work? * REQUIRED
  • Are you having any treatment/medication that could affect your ability to work? * REQUIRED
  • Do you think you may need any adjustments or assistance to help you to do the job? * REQUIRED

  • Food Handling Pre-Placement Screening Questions

  • This 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
  • Stomach pain, nausea or fever? * REQUIRED

  • At present are you suffering from any of the following;

  • Skin infections of the hands, arms or face? * REQUIRED
  • Boils/styles/septic fingers? * REQUIRED
  • Any disease or discharge from eye/ear/gums/mouth? * REQUIRED
  • Recurring skin or ear trouble? * REQUIRED
  • A recurring bowel disorder? * REQUIRED
  • Jaundice? * REQUIRED
  • Any open wounds or grazes? * REQUIRED
  • Do you have any disease or infection that can be transmitted via bodily fluids? * REQUIRED
  • Have you ever had or are known to be a carrier of typhoid or paratyphoid fever? * REQUIRED
  • Are you known to be a carrier of Salmonella Typhi or Paratyphi? * REQUIRED
  • Are you a carrier of any type of Salmonella? * REQUIRED
  • In 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
  • Do 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

  • 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 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.

  • Date Format: DD slash MM slash YYYY
 
 
 
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“Dependant” means:

(i) the spouse or partner and any brother, sister, parent, legal dependants (excepting children under the age of sixteen) of a Member or Non-Member who are also residing in the same household as that Member; and

(ii) the children or legal dependants of a Member or Non-Member that do not live in the Member’s or Non-Member’s household and who are aged 16 to 21 inclusive.

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