Albert Bartlett - Night Worker Occupational Health Form


Information About You

Title (Please tick as appropriate)

 

Surname  

Forname(s)   

Main Reason for Assessment: As required by the working time regulations, all night workers are offered an initial and an annual health assessment.   The assessment is voluntary and results stored securely.

Please tick the box which is most relevant. If the answer to any of the questions is ‘YES’, please give details.

Do you consider yourself to be disabled under the terms of the Equality Act 2010?

 

Have you been medically examined in the past two years in hospital or by a Specialist Doctor?

 

Are you taking any regular medicine(s) which require a strict timetable?

 

How Many hours sleep do you usually have?  

 

Do you suffer from, or have you ever had any of the following:-

Severe, frequent or prolonged headaches, migraines?

 

High / Low blood pressure?

 

Neurological problems (epilepsy, sleep deprivation, Bells palsy, stroke, multiple sclerosis)?

 

Asthma, hay fever, shortness of breath (do you use an inhaler)?

 

Heart or circulatory illness, varicose veins?

 

Chronic pain issues (IBS, Arthritis, Spinal or back pain, sciatica, Carpal Tunnel, Osteoarthritis, Crohn’s disease, repetitive strain injury)?

 

Stomach or intestinal disorders?

 

Diabetes (Type 1 or Type 2)?

 

Mental health or nervous troubles, depression, or anxiety, (even if mild)?

 

Do you drink alcohol? If yes, indicate how many glasses of wine, beer or spirits you drink each week?

 

Have you ever consulted your doctor about a substance misuse/abuse this includes alcohol?

 

PLEASE NOTE: If you have a medical condition by which you feel is affected by night working please state this in the box below.  It is your responsibility to provide this information to the Company.

 

EMPLOYEE DECLARATION:

I declare that the statements on this form are true and have been completed to the best of my knowledge/belief.  I am aware that any false statements may affect my employment.  I also agree to inform the relevant management if I become unwell or I am suffering from an infectious disease.  I agree to the referral to occupational health should there be anything of concern regarding night working in the above assessment.     

 

OFFICE USE:

Is the Employee a ‘Night Worker’ as defined by the Working Time Regulations?    YES   or  NO

 

Does the Employee require an Occupational Health referral?   YES  or  NO

 

Can the Employee work nights?   YES  or  NO

 

Leave this empty:

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Document name: Albert Bartlett - Night Worker Occupational Health Form
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Timestamp Audit
18th August 2025 9:20 am BSTAlbert Bartlett - Night Worker Occupational Health Form Uploaded by No-Reply Major Recruitment - onlineterms@major-recruitment.com IP 185.241.227.224
18th August 2025 10:00 am BSTID Recruitment - info@id-recruitment.co.uk added by No-Reply Major Recruitment - onlineterms@major-recruitment.com as a CC'd Recipient Ip: 185.241.227.224
18th August 2025 10:02 am BSTID Recruitment - info@id-recruitment.co.uk added by No-Reply Major Recruitment - onlineterms@major-recruitment.com as a CC'd Recipient Ip: 185.241.227.224
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