The contents of this form will be confidential to the Occupational Health Service and will not be revealed to anyone else without your consent.
Date of Birth
Contact Telephone Number
GP Name and Address
GP Telephone Number
Please answer either yes or no to the following questions:
Have you ever had any impairment/disability (physical or mental) that may affect your ability to undertake the tasks set out in the job description?
Do you need any special aids or adaptations to assist you at work whether or not you have a disability?
Are you having or anticipating any medication, treatment, therapy or investigations of any kind?
Have you ever had any illness, impairment or disability that may have been caused or made worse by work?
Have you ever left or been denied employment in an organisation on the grounds of ill health or been medically retired on the grounds of ill health?
Have you ever had any health problems that have been caused or made worse by work or any other health related problems that you need to declare that could affect attendance or performance at work?
Thank you for taking the time to complete this questionnaire!
I declare that the answers given in this questionnaire are true to the best of my knowledge and belief.
I consent to the results of this surveillance being shared with my employer:
If consent to write to your employer is withheld, this completed questionnaire will be held in your occupational health file but no further action will be taken.
Employee signature (type name to sign)