Pre-Employment Health Declaration

PRE-EMPLOYMENT HEALTH DECLARATION

PLEASE READ THE GUIDANCE NOTES BEFORE COMPLETING THE DECLARATION

Your answers to this questionnaire will be CONFIDENTIAL to the Occupational Health Unit and will not be given to anyone else without your written permission. The purpose of the questionnaire is to see whether you have any health problems 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. Our aim is to promote and maintain the health of all people at work. Before health clearance is given for employment you may be contacted by an Occupational Health Advisor. An appointment with the Occupational Health Physician may also be necessary. Please help us to help you by completing the questionnaire as fully as possible.

Personal Details

Surname

Title

Forename(s)

Date of Birth

Home Telephone

Mobile

Home Address

Postcode

Have you worked for Mindset in the last 5 years?

Yes No

Sickness Absence Record

Please detail the number of days you have been absent from work (or school) in the last two years. Outline the reasons for absence, please state if these absent dates where due to a disability.

How many days were you absent?

When was this?

Reason for absence

Have you any health problems which affect your ability to:

Drive

Yes No

Sit for long periods

Yes No

Stand

Yes No

Walk

Yes No

Climb Stairs

Yes No

Lift

Yes No

Use Hands

Yes No

Work at heights/ladders/Staging

Yes No

Work in a noisy environment

Yes No

Work with vibratory tools

Yes No

If you have answered ‘Yes’ to any of the above, please give details

Current Medical Treatment

Are you receiving any prescribed medications (tablets, inhalers, creams, injections, etc.) at the moment?

Yes No

Further details

Are you receiving any prescribed medications (tablets, inhalers, creams, injections, etc.) at the moment?

Yes No

Further details

Past Medical History

Have you had to leave a job due to ill health or been medically retired?

Yes No

Further details

Do you have, or have you ever had, any health condition which may have been caused, or made worse, by work?

Yes No

Further details

Do you consider yourself to have a disability? If yes please specify the disability

Yes No

Further details

Have you ever been declined ill health benefits or told you would not be eligible for them?

Yes No

Further details

Have you ever had any difficulties at work or in education as a result of a medical condition or learning difficulty (including autism, dyslexia, dyspraxia and Attention Deficit Hyperactivity Disorder – ADHD)

Yes No

Further details

Equality Act 2010

A disability is defined by the Equality Act 2010 as “A physical or mental impairment which has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities.

Yes No

Do you have any underlying medical condition

Yes No

Have you ever had any of the following?:

Allergies (including hayfever)

Yes No

Frequent headaches or migraine's

Yes No

Low or high blood pressure

Yes No

Any other blood condition or disorder

Yes No

Visual disturbances or defects such as blurred vision, colour blindness, scotoma, reduced visual field or blindness

Yes No

Hearing or ear issues

Yes No

Balance problems, vertigo, unexplained dizzy spells

Yes No

Fits, blackouts, epilepsy, fainting or unexplained periods of unconsciousness

Yes No

Nervous system diseases such as strokes, neuritis or multiple sclerosis

Yes No

Lung issues such as pneumonia, emphysema, asthma or bronchitis

Yes No

Malignancies or cancers

Yes No

Unexplained breathlessness, chest pain, angina or heart disease

Yes No

Bladder or Kidney conditions

Yes No

Liver conditions such as jaundice or hepatitis

Yes No

Metabolic conditions such as thyroid/adrenal gland disease or diabetes

Yes No

Rheumatism, Arthritis, gout or similar

Yes No

Infectious diseases

Yes No

Stress related problems, anxiety problems, depression or mental breakdowns

Yes No

Misuse of substances such as drugs, steroids or alcohol

Yes No

Any surgical procedures or operations

Yes No

Any other medical conditions, illness or disease

Yes No

Do you have, or have you ever had, any kind of back, joint/limb or muscle problem?

Yes No

GUIDANCE NOTES FOR MAKING A PRE-EMPLOYMENT HEALTH DECLARATION
1. Purpose of the Pre-Employment Health Declaration

This declaration is used for the following purposes:
• To help identify employees who need further health assessment or advice.
• To enable the Occupational Health Advisor to give an opinion on your fitness for your new joband advise on any reasonable adjustments that may be required.
• To be a simple record of your health status at the time you started your new job.
If you answer YES to any question, you will be contacted by an Occupational Health Advisor (OHA) and they will conduct a short interview over the phone. In certain cases, you may be asked to attend in person for an interview with an OHA or an Occupational Health Physician (OHP). They will then provide an opinion to the manager on your fitness for your new job. Very few applicants are found to be unfit for employment. Pre-employment assessments cannot be conducted retrospectively once an employee has been appointed. If a manager needs advice on a new employee’s fitness for post they must make a medical referral using the Medical Referral Form.
Failure to disclose a known medical condition may affect your work and could limit your rights in respect of the Equality Act 2010, as well as adversely affecting the Mindset’s ability to implement reasonable adjustments to assist you.

2. Function of the Occupational Health Advisors

Occupational Health Advisors are specialist Registered Nurses. They will provide an opinion to your manager on your fitness for a particular job. They can also provide advice regarding reasonable adjustments to the employee’s workplace, equipment or duties to help them start or continue employment.

3. Confidentiality of information

The declaration will be processed by Occupational Health Advisors and the information collected will be treated as confidential personal information.
Strict standards of medical confidentially and the Data Protection Act 1998 will apply to any additional information that you give to an Occupational Health Advisor or Physician. Occupational Health case notes are stored as a separate, medically confidential file. They are not shared with any other external department or agency.

An Occupational Health Advisor will provide the appointing manager with an opinion on your medical fitness for a particular job and advise them about any reasonable adjustments that are needed. However, specific details about your medical history can only be given to the appointing manager with your consent.

4. Data Protection Act 1998

Personal information collected on this declaration will be processed and stored in full accordance with the Data Protection Act 1998. The information collected will only be used for the stated purposes. It will not be shared with any external agency.

If a job application is successful, the declaration will be stored within the Occupational Health Unit. If a prospective employee does not start employment the declaration will be kept for no longer than necessary and then destroyed. This is usually for a period of up to six months to allow for the consideration and resolution of any disputes or complaints.

5. Equality Act 2010

If you are disabled for the purposes of the Equality Act, your employer has a duty to make 'reasonable adjustments' to make sure you are not put at a substantial disadvantage by employment arrangements or any physical feature of the workplace.

The Equality Act defines a person as having a disability where they have a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.

6. Which health conditions should be declared?

You should declare a physical or mental health condition by answering “yes” if that condition:

• Has caused previous episodes of long term sickness absences from work (more than 20 days in the last 12 months)
• Has caused previous repeated short term sickness absences (more than 6 separate absences in the previous 12 months)
• Was caused by a previous employment

• Is likely to cause future absences
• Is likely to become progressively worse and is likely to be made worse by your new work
• Is likely to prevent you carrying out your contracted duties or prevent you using equipment necessary to do your job • Is likely to prevent you working your contracted hours
• Causes any difficulties with communication, such as with hearing, speech or eyesight
• Prevents you operating the equipment necessary to do your job
• Prevents you using the personal protective equipment needed for that job
• Could put yourself or others at risk of injury
• Restricts your movements or posture
• Causes any difficulties with communication, such as with hearing, speech or eyesight
• It affects your mood, memory, ability to learn or social skills.
• It restricts your movement, strength or posture.
In addition you must declare by ticking the appropriate box any condition when:
• You are taking medication whose side effects may affect you at work
• A doctor has warned you not to do particular types of work or other activities
• If you have now or in the past had any drug or alcohol problems

7. Health declarations by Teachers and Teaching support staff

The pre-employment health assessment of teachers will be conducted in accordance with The Education (Teachers) Regulations 1993. Further guidance has been provided in DfEE Circular 4/99 and the DfEE publication Fitness to Teach (2000). The legislation has been interpreted as applying to other employees that regularly have contact with persons under 19 years old in an educational setting. This includes Teaching Assistants, and other support and administrative staff.

Teachers and support staff have a special duty under this legislation to disclose any known health conditions that may affect themselves or others at work.

Occupational Health Declaration/Consent Form

I declare that all the answers given in the above Pre-Employment Health Declaration are complete, true and I have not omitted any information, or mislead the Mindset. I understand this would be sufficient grounds for serious action to be taken against me, including dismissal.

I consent to the processing of my personal data included in this document for the purposes of the Data Protection Act 1998 and understand that the data is being collected

• To help identify employees who need further health assessment or advice.
• To enable the Occupational Health Advisor to give an opinion on fitness for a new job and to advise on any reasonable adjustments that may be required.
• To be a record of health status at the start of employment

Following my conditional offer of employment, I consent to:

• Being medically examined/assessed by an Occupational Health Physician if required. • My proposed employer being notified about my medical fitness and any adjustments that may be required to enable me to take up the duties required by the post. This will include information about all absences from work or education in the last two years.

I understand that I cannot be offered the post without a report/certificate from Occupational Health.

Signature

Date

Pre-Employment Health Declaration

PRE-EMPLOYMENT HEALTH DECLARATION

01157 860 399