Fit to Work Nights Assessment

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

Full name:

Sex:

Date of Birth:

Permanent address:

Job title:

National Insurance no.

Payroll no.

DO YOU SUFFER FROM ANY OF THE FOLLOWING HEALTH CONDITIONS?

IF YOU HAVE ANSWERED ‘YES’ TO THE ABOVE QUESTIONS YOU MAY BE ASKED TO SEE A DOCTOR OR OCCUPATIONAL HEALTH NURSE FOR FURTHER ASSESSMENT.

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

Data Protection: The information you provide on this form will be used by the Company for the purpose of assessing your fitness for work and will be handled in line with the Company’s Data Protection Policy.

In order for us to fulfil our contractual and/or legal obligations to you, it may be necessary to share some of this information with medical or healthcare professionals, should advice be needed to validate your fitness to undertake your role, or in support of any reasonable adjustments that may be required. In the event that this is necessary, we will seek your consent.

This document will be kept on your personnel file (hard copy and/or electronic) for the duration of your employment. We will retain your personnel file for a period of 7 years after your employment has ended (or in line with current legislation at that time). Please refer to the Company’s Data Protection Policy for more information relating to how the Company processes your personal data and your rights.