Worker Health Questionnaire – LIVE (candidate)

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.
Consent 1*
- 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.
Consent 2*
- On completion of the questionnaire, I consent to Innovate Healthcare providing a certificate, which may contain recommendations to my employer.
Second Choice*
- 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 .

Referrer Email:
Enter Email Confirm Email
Referrer Name :
Title :*
Candidate First Name(s) :*
Candidate Surname :*
Candidate Previous Names(s) If applicable :
Date of birth :*
Email address :*
Enter Email Confirm Email
Mobile Number :*
Current Address :*
Street Address ZIP / Postal Code
Job Title :*
Company Name :*
Cost centre / Department :*
Risk hazards:
THIS /// Exposure to class 3 or above genetically modified organisms? If so, which type?

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:*
- No
- Yes
- Exposure to Asbestos or other hazardous materials / chemicals

- Exposure to Lead

- Exposure to Biological Waste

- Exposure to Clinical Waste
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 :*

Night worker questionnaire

Do you suffer from any of these conditions?*

	No	Yes
a) Diabetes
b) Heart or circulatory problems
c) Stomach or intestinal problems, such as ulcers
d) Any medical condition which causes difficulty sleeping
e) Chronic chest disorders where night time symptoms may be particularly troublesome
f) Any medical condition where the timing of meals is particularly important
g) Any medical condition where the timing of meals is particularly important?
h) Any mental health problems which may be affected by night work?
i) Any other medical condition which may affect your ability to work safely at night?
j) Are you a new or expectant mother? (optional question)
k) If you have worked at night before, did this cause any ill health?

If ‘yes’ to any of the above, please give details i.e., when condition developed, is this new, how severe, its effect on you, how well controlled and treatment so far.
When condition developed, is this new, how severe, its effect on you, how well controlled and treatment so far.

Vaccs
Exposure to class 3 or above genetically modified organisms? If so, which type?
- Human tissue or blood samples
Vaccine /// Hepatitis B*
- No
- Yes
Date of 1st dose:*
DD slash MM slash YYYY
Date of 2nd dose:*
DD slash MM slash YYYY
Date of 3rd dose:*
DD slash MM slash YYYY
Date of booster(s):*
DD slash MM slash YYYY
Serology result date:*
DD slash MM slash YYYY
Serology result:*

Exposure to class 3 or above genetically modified organisms:
Exposure to class 3 or above genetically modified organisms? If so, which type?
- Mycobacteria TB or BCG
Vaccine /// BCG*
- No
- Yes
Date of 1st dose:*
DD slash MM slash YYYY
Scar visible?*
- Yes
- No

Exposure to class 3 or above genetically modified organisms:
Exposure to class 3 or above genetically modified organisms? If so, which type?
- Neisseria Meningitides
Vaccine /// Meningitis*
- No
- Yes
Date of 1st dose:*
DD slash MM slash YYYY
Date of 2nd dose:*
DD slash MM slash YYYY
Date of 3rd dose:*
DD slash MM slash YYYY
Date of booster(s):*
DD slash MM slash YYYY
Serology result date:*
DD slash MM slash YYYY
Serology result:*

Please click SUBMIT to complete the questionnaire.

Food handling
Overseas travel
Exposure to class 3 or above genetically modified organisms?
Exposure to respiratory allergens (house dust, animals, fish, animal product, mold, flour, wood dust, pollen, insects, other type of dusts)
Exposure to Lead or Aspestos
Contact with latex or other skin irritants
Chemical/fume exposure (COSHH)
Lead, asbestos or compressed air
Manual handling tasks
Repetitive tasks
Working with DSE (less than 5hrs a week)
Prolonged standing/walking/sitting
Lifting/carrying
Exposure to noise levels > 80dbA
Work at heights
Work in confined spaces
Electrical work
Working with vulnerable adults or children
Exposure to persons with challenging or aggressive behaviour
Driving LGV/PCVs
Driving Forklift Trucks
Working with dangerous machinery
Drug and alcohol screen required
Vibrating Machinery/Equipment
Night working (22:00 - 06:00)
Lone working
Shift working
Exposure to ionising radiation
Work with x ray chemicals
Working in a clinical setting but without regular clinical contact
Regular clinical contact with patients/service users
Performing EPP procedures
Exposed to clinical waste
Exposed to blood stained bodily fluids or blood
Will you be at risk of being bitten or deliberately injured by patients/service users
Manual Handling (heavy lifting/moving)

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands

Step 1 of 24