Work Health Assessment Questionnaire

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.
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
Date of Birth - must be dd/mm/yyyy format * REQUIRED
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

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
DD slash MM slash YYYY

Employee Details