Working Time Regulations Guide

Sample Health Questionnaire

This health questionnaire is provided for SAMPLE PURPOSES ONLY. Make sure you ask a qualified health professional to help you devise this form.

ARE YOU FIT TO WORK NIGHTS?

The purpose of this questionnaire is to ensure that you are suited to working at night. All the information you provide will be kept confidential.

TYPE OF WORK/ DURATION OF NIGHT WORK………………

  1. Surname
  2. First and second name/s
  3. Sex (M/F)
  4. Date of birth
  5. Permanent address
  6. Job title
  7. National insurance no.
  8. Department /clock no.

Do you suffer from any of the following health conditions? (Y/N)

Diabetes
Heart or circulatory disorders
Stomach or intestinal disorders
Any condition which causes difficulties sleeping
Chronic chest disorders, especially if night-time symptoms are troublesome
Any medical condition requiring medication to a strict timetable
Any other health factors that might affect fitness at work

If you have answered ‘yes’ to the above question, you may be asked to see a doctor or nurse for further assessment.

I, the undersigned, confirm that the above is correct to the best of my knowledge.

Signed……………………………………………….Date……….

ASSESSMENT

[this gives an indication of whether the worker is fit to work nights or should see a doctor or nurse for a medical examination]

Signed……………………………………………….Date……….

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