Step 1 of 5 20% 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 DetailsName * REQUIRED First Last Any Previous or Alternative NameDate of Birth - must be dd/mm/yyyy format * REQUIRED Date Format: DD slash MM slash YYYY Job Title * REQUIREDDaytime Tel: * REQUIREDEvening Tel:Email * REQUIRED Home Address * REQUIRED Street Address Address Line 2 City County 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 General Practitioner DetailsGeneral Practitioner Name * REQUIREDGeneral Practioner Address * REQUIRED Street Address Address Line 2 City County 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 Post & School/Academy DetailsPost Applied For * REQUIREDName of School/Academy * REQUIREDAge range to be taught * REQUIREDDepartment * REQUIREDStart Date - must be dd/mm/yyyy format Date Format: DD slash MM slash YYYY Past Employment with AuthorityHave you ever worked for the Authority before? * REQUIREDYesNo(If under a different name at the time please give previous name)Date(s) EmployedName of Last Teaching Post (or initial teacher training college if newly qualified)Address of Last Teaching Post Street Address Address Line 2 City County Postcode Please tick the appropriate box below and provide detailsHave you ever had any illness, medical problem or disability that may currently affect your ability to work safely as a teacher? * REQUIREDYesNoComments * REQUIREDHave you ever been treated in hospital? * REQUIREDYesNoPlease give reason(s) and dates * REQUIREDHave you seen a doctor in the last year for any kind of health problem? * REQUIREDYesNoPlease give reason(s) * REQUIREDAre you having any treatment or investigations of any kind at the moment? * REQUIREDYesNoComments * REQUIREDAre you waiting for any treatment, operation or investigation? * REQUIREDYesNoComments * REQUIREDHave you ever had any illness or health related problem that may have been caused or made worse by your work? * REQUIREDYesNoComments * REQUIRED Have you ever been medically retired from any job, or left any job because of ill health? * REQUIREDYesNoComments * REQUIREDHave you had any days off sick in the last 2 years? * REQUIREDYesNoPlease give number of days and reasons to the best of your recollection. * REQUIREDDo you have any eyesight problems not corrected with glasses? * REQUIREDYesNoComments * REQUIREDDo you have any hearing problems? * REQUIREDYesNoComments * REQUIREDDo you have any difficulties standing, bending, lifting or with any other movements? * REQUIREDYesNoComments * REQUIREDHave you ever had any back problem? * REQUIREDYesNoComments * REQUIREDHave you ever had any problem with your joints including pain, swelling or stiffness? * REQUIREDYesNoComments * REQUIREDHave you ever suffered from any mental illness, psychological or psychiatric problem, including depression, anxiety, nervous debility, nervous breakdown, schizophrenia or eating disorder? * REQUIREDYesNoComments * REQUIREDHave you ever had a drug or alcohol problem? * REQUIREDYesNoComments * REQUIREDHave you ever had fits, blackouts or epilepsy? * REQUIREDYesNoComments * REQUIREDHave you ever had any skin problems? * REQUIREDYesNoComments * REQUIREDHave you ever had any heart or blood pressure problems? * REQUIREDYesNoComments * REQUIRED Have you ever suffered from asthma, bronchitis or chest problems? * REQUIREDYesNoComments * REQUIREDIn 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? * REQUIREDYesNoComments * REQUIREDHave you ever had hepatitis or jaundice? * REQUIREDYesNoComments * REQUIREDDo you have any other medical conditions? * REQUIREDYesNoComments * REQUIREDAre you on any medication at present? * REQUIREDYesNoComments * REQUIREDDo you feel well at present? * REQUIREDYesNoComments * REQUIREDAre you allergic to anything? * REQUIREDYesNoWhat? * REQUIRED 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 * REQUIREDDate - must be dd/mm/yyyy format * REQUIRED Date Format: DD slash MM slash YYYY
