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Pre-Placement Questionnaire

Please download and fill out out our consent form and attach it at the end of this questionnaire.

Consent under Data Protection Act 1998 and the Access to Medical Reports 1988

Important information for you to read. (It can be supplied in an alternative format if required.)

Data Protection Act (also GDPR from 25th May 2018)

The general information we are asking about you is known as your personal data. Information about your health, medical history and any treatment that you have received is known as your sensitive personal data.

We require your informed consent in writing to obtain and process any health-related data about you. Before we can accept and process your personal and sensitive data we must have your explicit consent to do so.

Access to information

You have a right of access to information we hold about you on a health record. It is subject to medical confidentiality guidance which aims to protect you from physical or mental harm when reading about your state of health and means your doctor or the doctor acting on behalf your company will review the record before it is sent to you.

If on reading a record, you believe it is inaccurate or misleading you can request that an amendment is attached to a health record. If you want access to health record information your request must be made in writing to us. A check will be made to verify you are the person seeking the information. In certain circumstances a charge may be made for the release of information. We will write you if a charge is applicable.

Declaration

I agree to you processing personal and sensitive health related information about me.

I consentI do not consent

Pre-placement Health Questionnaire

PRIVATE & CONFIDENTIAL

The health of each candidate is considered individually and no decision to reject a candidate on medical grounds will be made without a medical examination or medical advice being sought You should notify us immediately if you have any serious illness after completing this form and before you take up the appointment offered as a result of your application. If you g‘ve any information that you know is false - or you withhold any information - your application may be rejected (or, if already appointed, you may be dismissed).

Section One - Recruitment - to be completed by the employer

To whom clearance should be returned?

Please tick boxes regarding job hazards
Manual HandlingHigh mental demandsRepetitive upper limb movementsNight work (We will send assessment form if required)None

Section Two - to be completed by the employee

Sex:
MaleFemale

Section Three - Medical History/Details

Do you, or have you ever suffered from any of the following:
(For questions 3.1 to 3.12 inclusively, indicate if you have ever suffered from any of the following conditions by specifying the appropriate condition.

3.1 Tuberculosis, pleurisy, asthma, bronchitis, or any other lung, throat or ear
complaint, including deafness.
YesNo

3.2 Any disorder of the heart, circulatory system, high blood pressure
YesNo

3.3 Persistent indigestion, gastric or duodenal ulcer, intestinal complaint or rupture
YesNo

3.4 Epilepsy or fits
YesNo

3.5 Any psychological or nervous complaint
YesNo

3.6 Diabetes, gout or any kidney or bladder complaint
YesNo

3.7 Any arthritis, slipped disc, rheumatism, back trouble or upper limb problem
YesNo

3.8 Dermatitis, other skin complaint or allergic condition
YesNo

3.9 Sleep apnoea, narcolepsy or cataplexy
YesNo

3.10 Frequent headaches or migraine
YesNo

3.11 Any eye complaint including blurred vision or eye discomfort
YesNo

3.12 Any other significant medical problem
(excluding coughs/cold or any of the conditions listed above)
YesNo

3.13 Do you normally wear glasses or contact lenses
YesNo

3.14 When did you last have an eyesight test

If you answer "Yes" to questions 3.15 to 3.20 then please provide details.

3.15 Do you have difficulty in recognising different colours?
YesNo

3.16 Have you ever failed a medical examination of any kind?
YesNo

3.17 Have you ever consulted, or been recommended to consult a medical specialist?
YesNo

3.18 Have you ever been in hospital as a patient?
YesNo

3.19 Are you currently on any treatment being prescribed by a Doctor?
YesNo

(If you answer “Yes” to 03.20 you may be sent a supplementary health questionnaire for completion so that the medical staff can assess appropriate and reasonable work adjustments for you)

3.20 With reference to the Disability Discrimination Act, do you have any physical or mental impairment, which significantly affects your daily living?
YesNo

The next question is to be answered by female applicants where the proposed emloyment might present a risk during pregnancy

3.21 Are you pregnant?
YesNo

If you have answered “yes” to any question on pages 2 or 3 of this questionnaire, with the exception of questions 3.13, 3.14 & 3.21 or 4.1, 4.17 & 4.18, please give details in the space below, continuing on a separate sheet of paper if necessary, and include:

• The date that the problem occurred and whether the condition is still present

• Details of any medication used or treatment undertaken in connection with the condition

• Details of any other medical condition not referred to within this questionnaire

Data Protection Act Clause and Declaration - Pre-placement health questionnaire Under the Data Protection Act 1998, (GDPR from 25th May 2018) the information you supply about yourself in this form is known as your personal data and information about your health, medical history and any treatment you have received is called "sensitive personal data”. The form including your "sensitive personal data” may be used by MacOH Ltd t/a MacOH to assess whether you are fit for the post for which your application is being considered. Your consent is required before this processing can take place. Please see the declaration below.

Section Five - Declaration

PLEASE READ CAREFULLY. By checking this declaration you will be giving your consent to the processing of the information you have supplied. If you do not understand the content of this form, the content or the effect of the declaration or you feel unable to give your consent, please contact the person responsible for recruitment mentioned on Part 1 for further information.

I CONFIRM THAT I HAVE READ AND UNDERSTOOD THE DATA PROTECTION NOTICE ABOVE. I HEREBY AGREE AND CONSENT TO THE PROCESSING OF THE INFORMATION THAT I HAVE SUPPLIED ABOUT ME. I declare that all the foregoing statements are true and complete to the best of my knowledge and belief and I am not aware of any other medical condition not referred to elsewhere in this questionnaire. I understand that any misrepresentation will invalidate my application and if employed, could lead to my dismissal. I understand that I may be required to undergo a medical examination by the company’s appointed medical adviser for pre-placement purposes only.

Section Six - DO NOT WRITE in this section of the Questionnaire

Initial review of PEHQ and further action required
Obtain further reportObtain consultant reportObtain GP reportArrange iMAIssue Functional Assessment questionnaire

Final Conclusion
FIT for positionUNFIT for positionEmployee Covered by DDA

Comments:

Please attach your consent form.