Introduction
By offering a Post Graduate Certificate in Education, the Graduate School of Education at the University of Bristolhas a responsibility to ensure that the health, safety and well-being of clients will not be put at risk. Applicants need a sufficient standard of health and physical fitness to enter and remain in the teachingprofession and therefore assessment of medical fitness for teaching work duties forms a key element of your application process.
All candidates offered a place are required to complete and return the enclosed confidential declaration of health questionnaire. The questionnaire asks candidates to disclose specified medical conditions and to provide information on any disability or health condition that may require support whilst they are studying.
The University of Bristol is committed to ensuring equality of opportunity for disabled students and those with health conditions. Most health conditions and disabilities, even if substantial, should not impede you from being accepted for training and will not raise fitness to practiceconcerns. If you have a condition which would make it impossible for you to work safely with childrenor for you to acquire the skills necessary to complete the course, even with adjustments and support, then you cannot be accepted onto the course. You should not assume that anydisability or health condition will prevent you from being able to take up your offered place. The health and fitness requirements are defined in the Fitness to Teach Guidance, DfEE December 2000 standards.
Please complete the enclosed questionnaire and sign the declaration in Section 4, and then arrange for your General Practitioner to complete Section 5. Please note that you will be responsible for any charges your GP may make.
Once you have completed all sections please returnthe questionnairein a sealed envelope by 1st July 2018 to: Occupational Health Service, University of Bristol, 1-9 Old Park Hill, Bristol, BS2 8BB. Please keep a copyand ensure the correct postage is paid to avoid any delays. Failure to return this questionnaire on time will result in a delay in processing your application and being accepted onto the course.
If you declare a disability or health condition which could affect you in your course, an Occupational Health Advisor will contact you for more information. The Graduate School of Educationwill be informed of any disability or health condition that would affect your fitness for course.
If you do not take up your place your form will be destroyed.
Occupational Health Service
1-9 Old Park Hill
Bristol
BS2 8BB
University of Bristol Occupational Health Service
Post Graduate Certificate in Education Student Health Questionnaire / CONFIDENTIALThe information you providewill be treated as confidential and seen only by the University of Bristol Occupational Health Service.Appropriate advice will be supplied to the University of Bristol, Graduate School of Education on your fitness for the course.Please complete in capitals using black ink.
Section 1: Personal Details
Title (Mr, Ms, Mrs, etc.)Family name
Given name(s)
Date of birth
Male / Female
Contact address
Home telephone number
Mobile Number
E-mail address
GeneralPractitioner (Name, address and telephone number)
PGCE subject
Section 2: Your Functional Capabilities
Do any of the following present you with difficulty? / Yes / Noa / Mobility e.g. walking, running, using stairs
b / Dexterity e.g. writing, using a computer
c / Communication e.g. speech, hearing
d / Vision e.g. visual impairment, colour blindness, tunnel vision
e / Learning e.g. dyslexia, dyspraxia, dyscalculia, impaired concentration
If yes to any of the above, give details e.g. extent of disability, any support needs or adjustments required at your place of study or work.
Section 3: Your Health
Please answer all of the following questions. If you answer yes, please give further details, continuing on a separate piece of paper if necessary.
1. Do you have any of the following? / Yes / Noa / Neurological disorder? e.g. epilepsy, fits or blackouts, multiple sclerosis
b / Endocrine disease? e.g. diabetes
c / Respiratory disease? e.g. pulmonary tuberculosis
If yes to any of the above,give details e.g. extent of disability, any support needs or adjustments required at your place of study or work.
2. Have you ever been affected by? / Yes / No
a / Sudden loss of consciousness? e.g. a fit or seizure
b / Chronic fatigue syndrome? (or similar condition)
c / An eating disorder? e.g. bulimia, anorexia nervosa, compulsive eating
d / Drug or alcohol dependency problems?
e / Mental health problems? e.g. anxiety, depression, schizophrenia, bipolar affective disorder, stress related illness, OCD or personality disorders
f / Have you ever been treated by a psychiatrist, psychotherapist or counsellor?
If yes to any of the above, give details e.g. reason, when condition developed, how long it lasted, its effects on you, treatment, and outcome, adjustments required at your place of study or work.
3. Are you currently taking any regular medication or receiving any treatment? Please circle. / Yes / No
If yes, give details
4. Do you have any disability or health condition not already mentioned for which you think that you may require support or adjustments during your education or training? Please circle. / Yes / No
If yes, give details
5. What is your height? / meters / 6. What is your weight? / kg
Section 4: Declaration
I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I understand that I may be contacted by a member of the Occupational Health Service for a more detailed assessment to determine my health and physical capability to teach. I consent to the Graduate School of Education being informed of any disability or health condition that requires support or that could affect my fitness for training to teach. I also understand that I have a responsibility to inform the Faculty if this declaration of health changes before coming to University and throughout the duration of the course.
I agree for the Occupational Health Service to use my mobile phone number to send me notifications, appointment reminders and passwords to encrypted documents sent via email (you can change your mind at any time by notifying us via ).
Signed: ______Date: ______
Section 5: Doctor’s Certificate
Your patient has been offered a place on the Postgraduate Certificate in Education course at the University of Bristol. All prospective teaching students need a sufficient standard of physical and mental health to enter and remain in the teaching profession. Candidates are asked to complete and return the declaration of health questionnaire providing information to assess whether the student is fit to safely complete placements and not put pupils at risk.
We require the applicants’ doctors to verify the health information provided by applicants on the basis of their knowledge of the patient.
.
Yes / No1. / Are you the applicant’s General Practitioner?
2. / Are you a relative of the applicant?
3. / Do you hold the applicant’s medical records?
4. / According to your records and knowledge of the applicant, do the answers to sections 2 and 3 appear correct? (please add any comments below)
5. / Are you aware of any additional medical information which may be relevant to this application? (please add any comments below)
Details;
PLEASE NOTE. A medical examination is not required. Any fee required for completion of the form is the responsibility of the patient.
Doctor’s Signature______Doctors name______
Date______/ Practice Stamp
For University Occupational Health Service Use Only
CommentsSigned
Date
Occupational Health Service
Completing your health declaration form
This guidance sheet provides answers to many frequently asked questions on completing your health declaration form.
Where do I send my completed form back to?
Occupational Health Service
Safety & Health Services
1-9 Old Park Hill
Bristol
BS2 8BB
What do I do if I lose the form?
Contact the Admissions Office at d they will send you another to submit.
What if I am unable to complete the form by the due date due to being away on a gap year or for any other reason?
It is advisable to notify Admissions and the Occupational Health Service of any expected delay.
What if my GP is delaying completing his section?
We must have this section completed in order for the form to be assessed, please do not send it back until your G.P has completed and signed section 5.
Do I need to send the form back by registered post?
You can return your form by registered post if you want confirmation of delivery, however if not standard post is sufficient. Please ensure you have paid the correct postage.
Do I need to keep a copy of the form?Yes, in case your form does not arrive for any reason and for your own reference – take two copies if you can one for home and the other to take with you to University.
University of Bristol Occupational Health Service
Questionnaire Checklist
Before sending your questionnaire to us, please ensure you have:
Completed sections 1, 2 and 3 with your personal and health information
Signed and dated the health declaration (section 4)
Had the Doctor’s Certificate (section 5) completed by your G.P. (this must include a signature and practice stamp - your questionnaire cannot be assessed without the certificate being fully completed)
Made a copy of the completed questionnaire for your records prior to sending
Used the correct postage (letters without the correct postage will not reach us, and will be returned to you by the Post Office)
1