WORKING
TIME REGULATIONS
SECTION
9: SAMPLE HEALTH QUESTIONNAIRE
This health
questionnaire is provided for sample purposes only. Make sure
you ask a qualified health professional to help you devise this
form.
ARE YOU
FIT TO WORK NIGHTS?
The purpose
of this questionnaire is to ensure that you are suited to working
at night. All the information you provide will be kept confidential.
TYPE OF WORK/
DURATION OF NIGHT WORK..................
1. Surname
2. First
and second name/s
3. Sex
M/F
4. Date
of birth
5. Permanent
address
6. Job
title
7. National
insurance no.
8. Department
/clock no.
| Do you suffer from
any of the following health conditions? |
Y/N |
| Diabetes
|
|
| Heart or circulatory
disorders |
|
| Stomach or intestinal
disorders |
|
| Any condition which
causes difficulties sleeping |
|
| Chronic chest disorders,
especially if night-time symptoms are troublesome |
|
| Any medical condition
requiring medication to a strict timetable |
|
| Any other health
factors that might affect fitness at work |
|
If you have
answered ‘yes’ to the above question, you may be asked to see
a doctor or nurse for further assessment.
I, the undersigned,
confirm that the above is correct to the best of my knowledge.
Signed.......................................................Date………….
ASSESSMENT
[this gives
an indication of whether the worker is fit to work nights or should
see a doctor or nurse for a medical examination]
Signed.......................................................Date………….
|
