Teacher Health Assessment – Health Assured

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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
First Last
Any Previous or Alternative Name
Date of Birth * REQUIRED
DD slash MM slash YYYY
Job Title * REQUIRED
Daytime Tel: * REQUIRED
Evening Tel:
Email * REQUIRED
Home Address * REQUIRED
Street Address Address Line 2 City County Postcode Country
General Practitioner Details
General Practitioner Name * REQUIRED
General Practioner Address * REQUIRED
Street Address Address Line 2 City County Postcode Country
Post & School/Academy Details
Post Applied For * REQUIRED
Name of School/Academy * REQUIRED
Age range to be taught * REQUIRED
Department * REQUIRED
Start Date
DD slash MM slash YYYY
Past Employment with Authority
Have you ever worked for the Authority before? * REQUIRED
- Yes
- No
(If under a different name at the time please give previous name)
Date(s) Employed
Name 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

Step 1 of 5

Employee Details

General Practitioner Details

Post & School/Academy Details

Past Employment with Authority

Please tick the appropriate box below and provide details

Declaration