Title Page
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Conducted by
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Date
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Address
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Report Number
Please read before completing the attached questionnaire.
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These questions relate to requirements for the job you are applying for.
We wish to ensure that your employment with us will not place yourself or others at risk.
The questions are also designed to identify any personal health issues that you have that could be potentially affected by work at the company or that would benefit from additional assistance.
Your information will be managed in accordance with the Health and Safety at Work Act (HSWA), 2015, Privacy Act 1993 and the Health Information Privacy Code 1994. Your information will be treated confidentially and will not be distributed to any other party without your consent
Should you have an injury in the future, however, we may require your consent to access the information pertaining to your injury to determine eligibility for cover.
If you wish to confidentially discuss any aspect of your health or if you are unclear as to the intent of the questions please do not hesitate to contact your supervisor of manager.
Appointments will not be confirmed unless there is satisfactory completion of this questionnaire and the information provided does not indicate an Occupational Health risk. You may be contacted for further information if what you have submitted in this questionnaire is not clear or complete, or raises any concerns.
Employee Details
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Name (first and last)
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Date of Birth
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Contact Phone Number
Health Questionnaire
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Have you been exposed to any health hazards on previous jobs
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If the answer is yes, please complete the section below
Previous Work
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Job
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List hazards you were exposed to here?
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Describe how you were or might have been affected?
General Questions
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Have you ever had a manual handling injury, sprain or strain, which has affected your<br>ability to work?
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If yes, please provide details here
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Has your ability to function or work ever been affected by an overuse problem or<br>repetitive strain injury e.g. DPI, OOS, RSI, HAVS etc ?
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If yes, please provide details here
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Has your ability to function or work ever been affected by back, neck, shoulder or arm problems?
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If yes, please provide details here
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Do you have any physical or mental health condition or injury that may impact on your ability to work now or in the future?
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If yes, please provide details here
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Do you take any medication/s which may impact on your ability to do the job?
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If yes, please provide details here
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Do you have any problem with your hearing which may impact on your ability to do the job?
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If yes, please provide details here
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Do you have any visual impairment which may impact on your ability to do the job?
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If yes, please provide details here
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Do you have a respiratory condition that may impact on your ability to do the job?
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If yes, please provide details here
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Do you have any needs relating to any other condition, injury or disability which may require support to do your job?
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if yes, please provide details
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If the applicant has tick yes to any of the above statements, they must be referred to an occupational health specialist for additional check-up before being offered any job
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Name of specialist(s) who employee has been referred to?
Declaration
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I declare to the best of my knowledge, the information I have given in this questionnaire is true and correct. I understand giving false or misleading information, or suppressing information may jeopardise my employment or be a reason for future disciplinary action
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Date/Time Completed
Job Risk Assessment (to be completed by a supervisor or manager before the commencement of any works)
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Types of Exposure (will the person be exposed to any of these conditions or environments)?
- Vibration to hands or arms?
- Vibration to body?
- Noise levels in excess of 85 decibels?
- Fumes or dust particles (e.g. asbestos)
- Hazardous chemicals?
- Blood borne viruses?
- Welding flashes?
- UV radiation
- Excessive stress or mental distraction
- Shift work?
- Heavy lifting?
- Extreme Temperatures (hot or cold)
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If any of the above has been ticked, the employee should be referred to an occupational health specialist for regular health monitoring
The frequency of this monitoring will be dependent on the nature and the frequency of exposure to the risk
Once a report has been received the company 'Health Check Register' must be updated
All information provided in this document will be kept confidential and only disclosed to other parties with the consent of the employee -
Name of specialist(s) who employee has been referred to?
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Supervisor/Manager Signature
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Date/Time Completed
