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  • 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 problems 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. You may be contacted by the Health Assured team and may need to be seen by an Occupational Health Nurse or Doctor.

    We are an Equal Opportunities employer and applicants with disabilities are encouraged to apply for jobs.

  • Candidate code cannot be confirmed or has expired or been cancelled- Please contact the person who issued the code to you.

  • Employee Details

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

  • General Practitioner Details

  • General Practioner Address * REQUIRED

  • Post & School/Academy Details

  • Date Format: DD slash MM slash YYYY

  • Past Employment with Authority

  • Have you ever worked for the Authority before? * REQUIRED
  • Address of Last Teaching Post

  • Please tick the appropriate box below and provide details

  • Have you ever had any illness, medical problem or disability that may currently affect your ability to work safely as a teacher? * REQUIRED
  • Have you ever been treated in hospital? * REQUIRED
  • Have you seen a doctor in the last year for any kind of health problem? * REQUIRED
  • Are you having any treatment or investigations of any kind at the moment? * REQUIRED
  • Are you waiting for any treatment, operation or investigation? * REQUIRED
  • Have you ever had any illness or health related problem that may have been caused or made worse by your work? * REQUIRED
  • Have you ever been medically retired from any job, or left any job because of ill health? * REQUIRED
  • Have you had any days off sick in the last 2 years? * REQUIRED
  • Do you have any eyesight problems not corrected with glasses? * REQUIRED
  • Do you have any hearing problems? * REQUIRED
  • Do you have any difficulties standing, bending, lifting or with any other movements? * REQUIRED
  • Have you ever had any back problem? * REQUIRED
  • Have you ever had any problem with your joints including pain, swelling or stiffness? * REQUIRED
  • Have you ever suffered from any mental illness, psychological or psychiatric problem, including depression, anxiety, nervous debility, nervous breakdown, schizophrenia or eating disorder? * REQUIRED
  • Have you ever had a drug or alcohol problem? * REQUIRED
  • Have you ever had fits, blackouts or epilepsy? * REQUIRED
  • Have you ever had any skin problems? * REQUIRED
  • Have you ever had any heart or blood pressure problems? * REQUIRED
  • Have you ever suffered from asthma, bronchitis or chest problems? * REQUIRED
  • In the last 12 months, have you had a cough for more than 3 weeks, coughed up blood or had any unexplained weight loss or fever? * REQUIRED
  • Have you ever had hepatitis or jaundice? * REQUIRED
  • Do you have any other medical conditions? * REQUIRED
  • Are you on any medication at present? * REQUIRED
  • Do you feel well at present? * REQUIRED
  • Are you allergic to anything? * 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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