Occupational Health Form

All the information on the form will be treated in strict confidence and will not be divulged to any third party without written consent.

Personal Details

Name *

First

Last

Date *

Branch *

Department *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth (DD/MM/YYYY) *

Mobile *

Email *

Section A - Medical History

Please answer all of the following questions. If you answer Yes please give details. Have you ever had or do you have now, any of the following?

Impairment which may affect your ability to work safely? *

Yes
No
Don't know

Details

Eyesight problems not corrected with glasses/contact lenses? *

Yes
No
Don't know

Details

Hearing problems not corrected with a hearing aid? *

Yes
No
Don't know

Details

Difficulty in standing, bending, lifting or other movements? *

Yes
No
Don't know

Details

Any kind of back problem? *

Yes
No
Don't know

Details

Have you ever suffered discomfort when using a computer keyboard? *

Yes
No
Don't know

Details

Any mental illness or psychological problems e.g. depression nervouse breakdowns, eating disorder, substance misuse or other? *

Yes
No
Don't know

Details

A drug or alcohol problem? *

Yes
No
Don't know

Details

Fits, blackouts or epilepsy? *

Yes
No
Don't know

Details

Any allergies? *

Yes
No
Don't know

Details

Asthma, bronchitis or chest problems? *

Yes
No
Don't know

Details

Treatment for TB? *

Yes
No
Don't know

Details

In the last 12 months have you had a cough for more than 3 weeks, ever coughed up blood or had any unexplained loss of weight or fever? *

Yes
No
Don't know

Details

Diabetes, thyroid or gland problems? *

Yes
No
Don't know

Details

Any illness which may have caused or been made worse by your work? *

Yes
No
Don't know

Details

Episodes of chest pain or breathlessness? *

Yes
No
Don't know

Details

Suffer from heart disease or high blood pressure? *

Yes
No
Don't know

Details

Are you at present taking or receiving any form of medication? *

Yes
No
Don't know

Details

Any operations? *

Yes
No
Don't know

Details

Been retired on the grounds of ill health? *

Yes
No
Don't know

Details

Are you waiting for or receiving treatment for any medical or mental health *

Yes
No
Don't know

Details

Have you ever suffered with stress associated with work? *

Yes
No
Don't know

Details

Is there any additional relevant information regarding your health not covered in the above questions? *

Yes
No
Don't know

Details

Section B - Food Handlers

You have a duty to report to your employer of any changes to your health.

Any skin conditions? (please specify) *

Yes
No
Don't know

Details

Hepatitis or jaundice? *

Yes
No
Don't know

Details

Dysentery, typhoid, paratyphoid, fever, food poisoning, salmonella, severe gastroenteritis or diarrhea? *

Yes
No
Don't know

Details

Any discharge from ears or current/recurrent ear infections? *

Yes
No
Don't know

Details

Section C - Sickness Absence

How many days have you lost from work or school during the past year? *

What was this due to?

Section D - Immunisations / Blood Test Results

Certain jobs carry with them a risk of infection. In such cases we offer the facility of being immunised to prevent the risk of infection. Please provide details below of your immunisation history. When attending, please bring with you proof of identity e.g. passport or hospital identity badge.

Immunisations

HB test (Heaf, Tine, Mantoux)

Yes
No
Don't know

Date dd/mm/yy

Results

BCG [TB vaccinations]

Yes
No
Don't know

Date dd/mm/yy

Results

Tetanus

Yes
No
Don't know

Date dd/mm/yy

Results

Poliomyelitis

Yes
No
Don't know

Date dd/mm/yy

Results

Rubella [German Measles]

Yes
No
Don't know

Date dd/mm/yy

Results

Hepatitis A

Yes
No
Don't know

Date dd/mm/yy

Results

Hepatitis B (Date of last immunisation)

Yes
No
Don't know

Date dd/mm/yy

Results

Meningitis B

Yes
No
Don't know

Date dd/mm/yy

Results

Blood test results

Hepatitis B

Yes
No
Don't know

Date (DD/MM/YYYY)

Results

Rubella [German Measles]

Yes
No
Don't know

Date dd/mm/yy

Results

Varicella (Chicken pox)

Yes
No
Don't know

Date dd/mm/yy

Results

Chest X-ray [clear)?

Yes
No
Don't know

Date dd/mm/yy

Results

Others

Please state

Date dd/mm/yy

Results

Section E - HIV/AIDS

The company operates a policy of non-discrimination. In line with company policy, and National Guidelines, 'HSC 1998/226 - Guidelines on the Management of AIDS/HIV Infected Health Care Workers and Patient Notification' (updated August 1999), you must inform the Director of Training and Quality if you know or suspect you are HIV positive or have an AIDS defining illness. This information is necessary in order that a Risk Assessment may be undertaken to your safety and that of others.

If you know or suspect you are either HIV antibody positive or have AIDS, please tick the appropriate box. This information is absolutely confidential to the Director of Training and Quality.

Yes
No

Section G - Night Workers

The following section is to be completed only by those members of staff who regularly undertake night duty. Have you suffered from and been treated for any of the following. If Yes, please give details of the condition and whether they are ongoing at present.

Blackouts/Fainting fits/Epilepsy

Yes
No

Back or limb disorders

Yes
No

Diabetes

Yes
No

Heart or circulatory disorders

Yes
No

Stomach, bowel or intestinal disorders

Yes
No

Any conditions affecting sleep

Yes
No

Asthma/ bronchitis

Yes
No

Anxiety/depression

Yes
No

Nervous or mental disorders

Yes
No

Serious operations/accident/injuries

Yes
No

Do you have any other ongoing health problem?

Yes
No

Are you currently taking drugs or medicines prescribed by a doctor or purchased from a pharmacy?

Yes
No

Please give the name of the drug and dosage

Do you consider that you have any form of medical condition that may affect your ability to work at night?

Yes
No

Please explain

Have you ever felt that night work was harming your health?

Yes
No

Do you wish to discuss anything with a health advisor?

Yes
No

Section H - COVID-19 Vaccination Status

Please select from the options below your current vaccination status for COVID-19.

What is your current vaccination status? *

First vaccination
Fully vaccinated
Not vaccinated

Section I - Declaration

I declare that the information on this form is true to the best of my knowledge. Further, I understand that if I should be found to knowingly make a false statement regarding my medical history either in answering the above questions or to the Company's Director of Quality and Training, or should I conceal any material fact, the Company can terminate my contract without notice.

Personal Details

Section A - Medical History

Section B - Food Handlers

Section C - Sickness Absence

Section D - Immunisations / Blood Test Results

Section E - HIV/AIDS

Section G - Night Workers

Section H - COVID-19 Vaccination Status

Section I - Declaration

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