Pre-employment medical questionnaire form

Employees starting jobs that involve work with hazards (eg sensitising chemicals, allergens etc) or safety-critical activities (eg night work, driving a vehicle etc) must complete and return the new starter medical questionnaire before commencing employment. This questionnaire collects specific job-related information about a post, and relevant health information about the new starter. This information is then assessed by OHS advisers who can: 

(i) assess the candidate's medical capability to do the job for which they have applied: this will include assessing whether there are any statutory and legal reasons why an individual may not carry out particular work: for example, health and safety regulations would mean that a candidate with epilepsy would not be allowed to undertake a post involving driving; and 

(ii) provide advice to departments to ensure that none of the role's duties will adversely affect any pre-existing health conditions the candidate has declared.

An answer must be provided for all questions. The information will be treated in confidence by the Occupation Health Adviser.

PLEASE COMPLETE IN CAPITAL LETTERS

Title (circle):

Full name:

Address:

Contact telephone:

Date of birth:

 

GP name:

Address:

Telephone:

 

Position applied for:

 

Occupational hazard history:

Please note the job titles, dates, and nature of any known hazards to which you have been exposed.

.....................................................................................................................................................................................

 

MEDICAL HISTORY

Please complete the following questions by ticking the appropriate box. If the answer is yes, give details including (a) date, (b) amount of time lost from work/school, (c) treatment, as appropriate.

Have you ever suffered from any of the following illnesses?

Visual defects/eye conditions (including colour-blindness):

[Yes] [No] If yes, please give details:

.....................................................................................

Hearing defects/ear conditions:

[Yes] [No] If yes, please give details:

.....................................................................................

Severe anxiety, depression,

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731 words. Last updated on 28/11/18. ©2020 HRDocBox.