Food Handling Questionnaire | Health Assured

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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
First Last
Date of Birth - must be dd/mm/yyyy format * REQUIRED
Date Format: DD slash MM slash YYYY
Gender * REQUIRED
- Male
- Female
Job Title * REQUIRED
Department * REQUIRED
Manager
Contact Tel: * REQUIRED
Email * REQUIRED
Home Address * REQUIRED
Street Address Address Line 2 City Region Postcode Country
Your Company/Organisation: unknown company
Have you worked for the company/organisation before? * REQUIRED
- Yes
- No

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
- Yes
- No
Additional Comments * REQUIRED
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Are you having any treatment/medication that could affect your ability to work? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Do 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 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
- Yes
- No
Additional Comments * REQUIRED
Stomach pain, nausea or fever? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
At present are you suffering from any of the following;
Skin infections of the hands, arms or face? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Boils/styles/septic fingers? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Any disease or discharge from eye/ear/gums/mouth? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Recurring skin or ear trouble? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
A recurring bowel disorder? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Jaundice? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Any open wounds or grazes? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Do you have any disease or infection that can be transmitted via bodily fluids? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Have you ever had or are known to be a carrier of typhoid or paratyphoid fever? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Are you known to be a carrier of Salmonella Typhi or Paratyphi? * REQUIRED
- Yes
- No
Additional Comments * REQUIRED
Are you a carrier of any type of Salmonella? * REQUIRED
- Yes
- No
Additional Comments * 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
- Yes
- No
Additional Comments * 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
- Yes
- No
Additional Comments * REQUIRED
Countries visited in the last 6 weeks: please specify:

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.
Please enter name as a signature * REQUIRED
Date - must be dd/mm/yyyy format * REQUIRED
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.