Fit to Work Nights Assessment FORM

Type of work/duration of night work
Full name*
First
Email*
Sex*
Date of birth*
Permanent address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Job title*
National Insurance No.*
Payroll No.*
Do you suffer from any of the following health conditions? (Tick conditions below if yes)
- Diabetes
- Heart of 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
TO CONTINUE PLEASE CLICK SUBMIT AND READ THROUGH THE DOCUMENT THEN SIGN AT THE BOTTOM.
CLICK AGREE AND SIGN THIS WILL SEND THE DOCUMENT BACK TO IGLOO

Type of work/duration of night work