Health surveillance relates to procedures to detect work-related ill health at an early stage, and acting on the results. The main aims are to safeguard the health of you, the employee. In the case of hand-arm vibration, one of the specific aims is to prevent employees developing an advanced stage of hand-arm vibration syndrome (HAVS) associated with disabling loss of hand function. The purpose of the questionnaire is to determine whether you may any have any relevant health problems, specifically related to hand-arm vibration syndrome (HAVS), that could affect your ability to undertake the duties of the post you have been offered and/or place you at any risk in the workplace.
The questionnaire will take approximately 5 to 10 minutes to complete. A response to all questions is required. You will be prompted to revisit any questions that require a response prior to moving to subsequent questions. Your progress will be saved should you start the questionnaire and need to return to it at a later date.
Your answers to this questionnaire will be CONFIDENTIAL to Innovate Healthcare and will not be provided to anyone else without your permission. However, we may recommend further health surveillance/assessment to your employer based on the answers you provide. These recommendations will be aligned to statutory guidance published by the Health and Safety Executive which is informed by the Control of Vibration at Work Regulations (2005).
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I consent that if an escalation is needed, I will be referred to a third-party provider for an additional clinical appointment. I will receive details of who the third-party provider is upon appointment booking and confirmation, and will be asked for consent again before any further assessment takes place. I understand that the third-party provider will also assume the role of the data handler for all further assessment past Level 1 and/or Level 2 HAVS screening. Innovate remains the data handler for my Level 1 and/or Level 2 HAVS screening information.

On completion of the questionnaire, I consent to Innovate Healthcare liaising with the referrer when recommendations for further Health surveillance are identified.

I consent to Innovate Healthcare gathering and storing the data provided in the questionnaire. Please take a look at our privacy policy to find out more about how we look after your information.

I understand that I have the right to revoke my consent at any time. However, any data processing that occurs before consent is revoked will still be valid. I can revoke my consent by writing to Innovate at the address given on this form (via post or email).

I understand that I have the right to request access to any personal information relating to me that is held by Innovate.