Health & Wellbeing @ Work Centre

Level 1 DrysdaleBuilding

Northampton Square

London EC1V 0HB

Phone: 44 (0) 20 7040 5999

Fax: 44 (0) 20 7040 8867

Confidential Work Health Assessment

The information requested on this form is required to ensure that you are safely able to undertake the job you have been offered and to enable us to make adjustments to accommodate any disability you may have. If your role involves clinical work, driving or manual handling you will be sent a further slightly more detailed questionnaire to ensure your health and safety.
You may be contacted by us for clarification of the information on the form and may also be required to attend the Occupational Health Service for a discussion or an examination with the doctor or nurse.

If have difficulty completing this form, kindly contact us using the contact details above.

Data Protection Statement

The information given in this health questionnaire is confidential to the Occupational Health Service staff and details will not be revealed to a third party without your permission. In accordance with the Data Protection Act 1998, the information given on this form will be used for occupational health assessment purposes and will not be released to anyone who does not require it for this purpose. Any recommendations (not medical information) such as adjustments required or fitness to work made on the basis of this assessment will be forwarded as necessary to Human Resources.

This form will be placed on your Occupational Health file and kept throughout your employment, after which it will be stored securely as required by Health and Safety legislation. Where an external provider is used to provide some aspect of Occupational Health care to the University there will be a contract between the Data Controller (the University) and the Data Processor (the Occupational Health Service).

I have read the above statement and agree to the personal data contained in this form being processed for the purposes stated
Name: / ------/ Signature: / ------/ Date: / ------
About You
Title: (Ms / Miss / Mrs / Mr / Dr / Professor) / MsMrsMissMrDrProfessor / Male: / Female:
Surname / Family Name: / First Name:
Previous Names (if Applicable): / Date of Birth:
Line Manager (if known): / Proposed Job Title:
School / Professional Service: / Department:
Site:
Email Address: / Daytime Contact Number:

Please make sure you give us a reliable daytime contact number to prevent delays in your recruitment process

Please complete the questionnaire as fully as possible. Failure to answer all questions will result in your form being returned to you and may delay your clearance and employment start date.

Please complete this form in BLACK ink

  1. Do you have any illness / impairment / disability (physical or psychological) which may affect your ability to undertake your work?

Yes / If YES , please give details below: / No
Further information about your currentillness/impairment / disability
  1. Do you think you may need any adjustments or assistance to helpyou to do the job?

Yes / If YES , please give details below: / No
Further information about adjustments or assistance required
  1. Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?

Yes / If YES , please give details below: / No
Further information about your previousillness/impairment / disability
  1. Are you having, or waiting for treatment (including medication) or investigations at present?

Yes / If YES, please provide further details of the condition, treatment and dates. / No
Condition / Treatment / Dates
  1. Have you had any sickness absence in the past two years?

Yes / If YES , please give details below: / No
Date / Reason for absence / Duration of absence
DECLARATION
I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.
Signed: / …………………………………………………………………………………. / Date: / ……………………………………….
Next Steps
Please print this form, sign it and send it to the occupational health service as soon as possible.
You can return your signed form in a number of ways:
By post to: / By fax to: / Scan and email to:
Occupational Health Service
Health & Wellbeing @ Work Centre,
Level 1, Drysdale Building,
City University London,
10 Northampton Square,
London. EC1V 0HB / 020 7040 8867 /

To ensure confidentiality, please send this form only to the occupational health department.