PPQ | Innovate Healthcare

The purpose of the questionnaire is to determine whether there may be any relevant 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.
You will have received the name of your HR representative, Referrer cost centre, reference number and referrer email address, in your email inviting you to complete the questionnaire. You will need these details once you start the questionnaire.
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 adjustments or assistance to your HR representative, when it is Innovate Healthcare’s opinion that adjustments are required. 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 the Innovate Healthcare team and may need to be seen by an Occupational Health advisor or physician.
*
- I consent to an Innovate Occupational Health Case Manager contacting me by telephone or email following completion of the questionnaire, in the event that additional information may be required.
*
- On completion of the questionnaire, I consent to Innovate Healthcare providing a certificate, which may contain recommendations to my employer.
*
- I consent to Innovate Healthcare gathering and storing the data provided in the questionnaire, for further information into how we manage your data please review our Privacy Policy .

Please input the email address of the person who asked you to complete this form. Please note this is where your outcome certificate will be issued.
Referrer Email:*
Enter Email Confirm Email
Referrer Name :*
Your email address:*
Enter Email Confirm Email
Cost Centre :*
Gender:*
Title :*
Candidate Surname :*
Candidate First Name(s) :*
Candidate Previous Names(s) If applicable :
Date of birth :*
Job Title :*
Company Name :*
Manager :*
Site / Department :*
Current Address :*
Address Line 1 Address Line 2 Postcode :
Mobile Number :*

Based on the information provided this employee has :
1. Have you lived continuously in the UK for the last 5 years?*
- Yes
- No
1a. If no, please list all of the countries that you have lived in over the last 5 years:*

2. Have you worked in any environments, within the UK, that may present a risk to your physical health, in the previous 5 years? A hazardous workplace environment would include but is not limited to the following:*

- Exposure to Asbestos or other hazardous materials / chemicals

- Exposure to Lead

- Exposure to Biological Waste

- Exposure to Clinical Waste
- No
- Yes
2a. Please provide further information :*

3. Do you have any illness/impairment/disability (physical or psychological) which may affect your work?*
- No
- Yes
3a. Please provide further information :*

4. Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?*
- No
- Yes
4a. Please provide further information :*

5. Are you having, or waiting for treatment or investigations at present?*
- No
- Yes
5a. Please provide further information :*

6. Do you think you may need any adjustments or assistance to help you to do the job?*
- No
- Yes
6a. Please provide further information :*

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ARGENTINA
ARMENIA
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SAINT KITTS AND NEVIS
SAINT LUCIA
SAINT VINCENT AND THE GRENADINES
SAMOA
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SAO TOME AND PRINCIPE
SAUDI ARABIA
SENEGAL
SERBIA
SEYCHELLES
SIERRA LEONE
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SOMALIA
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SWEDEN
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TOGO
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UNITED STATES OF AMERICA
URUGUAY
UZBEKISTAN
VANUATU
VENEZUELA
VIETNAM
YEMEN
ZAMBIA
ZIMBABWE

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