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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 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
  • Date Format: DD slash MM slash YYYY
  • Gender * REQUIRED
  • Home Address * REQUIRED
  • Your Company/Organisation: unknown company

  • Have you worked for the company/organisation before? * REQUIRED
  • 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
  • Have you ever had any illness/impairment/disability which may have been caused or made worse by your work? * REQUIRED
  • Are you having any treatment/medication that could affect your ability to work? * REQUIRED
  • Do you think you may need any adjustments or assistance to help you to do the job? * 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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