Easter N/S Form
Easter N/S Form
Confidentiality
Full Name
*
Date of Birth
*
Company Name
*
Job Title/Position
*
Work Pattern
*
Phone
*
Consent & Declaration
I give my consent for Albacare Limited to carry out a health assessment for night time work.
I understand that this is necessary for health and safety reasons and the results of this assessment, including recommendations (but not the detailed medical findings) will be given to my employer, to assist in maintaining a healthy and safe workplace.
I declare that, to the best of my knowledge, the information given above and in the answers to the health questionnaire is true and complete.
I understand that failure to disclose relevant information or providing false information may affect my employment.
I give my consent
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Yes
No
Please answer the following
Do you currently work permanent night shifts?
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Yes
No
If yes, please provide details.
Do you currently work a rotating shift system which includes nights?
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Yes
No
If yes, please provide details
Do you have any concerns about your health at present?
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Yes
No
If yes, please provide details
Have you ever had?
Epilepsy/fainting attacks/blackouts?
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Yes
No
If yes, please provide details
Depression / anxiety mental illness/nervous debility?
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Yes
No
If yes, please provide details
Migraine/frequent headaches?
*
Yes
No
If yes, please provide details
Kidney/bladder trouble?
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Yes
No
If yes, please provide details
Arthritis/rheumatism/back trouble?
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Yes
No
If yes, please provide details
Ear trouble?
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Yes
No
If yes, please provide details
Eye trouble?
*
Yes
No
If yes, please provide details
Dysentery/hepatitis/typhoid/paratyphoid?
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Yes
No
If yes, please provide details
Do you suffer from?
Diabetes – Type 1 or Type 2?
*
Yes
No
If yes, please provide details
Heart or circulatory problems?
*
Yes
No
If yes, please provide details
A medical condition where regular timing of meals important?
*
Yes
No
If yes, please provide details
A chronic chest disorder?
*
Yes
No
If yes, please provide details
A sleeping disorder or medical condition affecting your sleep?
*
Yes
No
If yes, please provide details
Are you currently on prescribed medication?
*
Yes
No
If yes, please provide details
Are you aware of any other health matters that may affect your fitness to undertake night duties?
*
Yes
No
If yes, please provide details
DECLARATION
I certify that the answers to the above questions are correct to the best of my knowledge.
Enter your full name to confirm the above information
*
Submit
