NIGHT WORKER PACKAGE

• Property name

• Conducted on

  Date

• Prepared by

• Job Title

• Employee Name

• Job Title

• Property

• Date of birth

• Version 3 (November 2020)

Night Worker Medical Questionnaire

• Have you ever had any of the following?

Health Conditions

• Epilepsy / fainting attacks / blackouts

  Yes

  No

  N/A

• Dysentery / hepatitis / typhoid / paratyphoid

  Yes

  No

  N/A

• Do you suffer from any of the following health conditions?

• Migraine

  Yes

  No

  N/A

• Kidney / bladder trouble

  Yes

  No

  N/A

• Arthritis / rheumatism / back trouble

  Yes

  No

  N/A

• Ear trouble

  Yes

  No

  N/A

• Eye trouble

  Yes

  No

  N/A

• Diabetes

  Yes

  No

  N/A

• Heart or circulatory disorders

  Yes

  No

  N/A

• Stomach or intestinal disorders

  Yes

  No

  N/A

• Any conditions which causes difficulties sleeping

  Yes

  No

  N/A

• Chronic chest disorders (especially if night-time symptoms are troublesome)

  Yes

  No

  N/A

• Do you

• Take any prescribed medication

  Yes

  No

  N/A

• Have any medical condition required taking medication to a strict timetable

  Yes

  No

  N/A

• Have any medical condition where regular timing of meals are important

  Yes

  No

  N/A

• Know of any other health factors that might affect your fitness at work

  Yes

  No

  N/A

• List condition

I confirm the above information is correct to the best of my knowledge (EMPLOYEE)

• Name

• Signature:

  Sign

• Date

  Date

Night Workers Employer’s Assessment

• Property

• Employees name

• After reviewing the questions, my assessment is that the employee CAN work nights

  Yes

  No

  N/A

• After reviewing the questionnaire, my assessment is that the employee: CANNOT work nights

  Yes

  No

  N/A

• IF NO Reason: should see a doctor or nurse for a medical examination to assess whether s/he can work nights

• Completed by

• Job Title

• Date

  Date

• Signature

  Sign

• Further actions: Contact Healthandsafety@omnifm.com or HR@omnifm.com if you need further clarification