Questionnaire

Keltbray - Pre Placement Questionnaire
Private and Confidential

Part A Job information


  • HR contact details
  • Line Managers contact details
Keltbray - Pre Placement Questionnaire
Private and Confidential

Part B

Job information

  • Gender
  • General practitioner detials
Keltbray - Pre Placement Questionnaire
Private and Confidential

Does the post or working environment require: (please select either yes or no for each question)

  • Night work (i.e. working between 11pm-6am)

  • Manual Handling/physical work

  • Handling of known hazardous substances, toxic, ionising materials, etc.

  • Working with respiratory sensitisers, i.e. Isocyanates, known asthmagens, flour/grain/hay, soldering flux, laboratory animals, wood dusts, glues/resins, etc.

  • Regular use of Display Screen Equipment

  • Regular telephone use e.g. call centre environments

  • Potential exposure to a noisy environment

  • Food handling

  • HGV / LGV Driving/ Fork Lift Truck Driving

  • Potential exposure to bodily fluids

  • Business travel abroad

  • Working outside

  • Working at height

  • Working with electrics or need accurate colour vision

  • Working in confined spaces

  • Working in extreme temperatures

  • Lone working

  • Use of power/vibrating tools

  • Other

Keltbray - Pre Placement Questionnaire
Private and Confidential

Occupational History

Please indicate whether you have been exposed to any of the following in previous employment: (please select either yes or no for each question)

  • Heavy physical work

  • Operating/ Moving Machinery

  • Noisy work environment

  • Vocational driving

  • Vibrating/power tools

  • Display Screen Equipment (DSE)

  • Working at Height

  • Dusty environments

  • Chemicals/ gases

  • Night/Shift work

  • Confined spaces/ Working alone

  • Lead

  • Asbestos

  • Other

Keltbray - Pre Placement Questionnaire
Private and Confidential

Health information

Please answer the following questions to the best of your ability. If you answer yes to any question, please give appropriate details in the space provided. Please include relevant dates, treatments, lengths of absence from work, long term effects, any limitations, etc.

Have you ever suffered from the following:

  • Does your role involve Safety Critical Work?

  • Are you currently or have you ever been under any medical supervision?

  • Are you currently taking any tablets/ medicines/ drugs prescribed or not prescribed?

  • Are you currently having treatment, have you ever attended hospital as an in/out patient, or are you waiting for an in/out patient appointment? (e.g. physiotherapy)

  • Do you have a health problem that you believe would be defined as a Disability under the Equality Act, i.e. affects your ability to carry out normal day to day activities for at least 12 months/likely to last for more than 12 months?

Keltbray - Pre Placement Questionnaire
Private and Confidential

Declaration

This form asks questions about your employment history, past and present health. It will be used to make an assessment of your health in relation to your employment. This Pre-Placement Health Questionnaire will stay within Occupational Health, however a fitness report based on the information disclosed in this form will be sent to Management and/or Human Resources. An Occupational Health Advisor may contact you by telephone to discuss any health issue you have disclosed in greater detail if necessary.

I declare that the information given in this document is true, accurate, complete and to the best of my knowledge. I understand that failure to disclose information could affect my employment and could put my health and the health of others at risk. I consent to a telephone and / or face-to-face consultation and if necessary a medical interview and examination. I understand that now, and in the future, I have a duty to report the development of any health condition(s), or medication(s), which could affect safety, concentration or performance at work.

I consent for my company to add my personnel record to the Constructing Better Health (CBH) database* (where applicable).

I consent for the results of my health screening to be uploaded to the OH database. I understand that my employer will only be able to see my medical outcome, medical expiry date and any recommendations. I am aware that they will not see any medical/clinical information.

I consent to personal information and the results of screening (occupational health records) to be stored as hard copy and on secure computer systems accessible only to KML Occupational Health professionals.

I understand that KML OH have a duty to report any relevant health concerns to my Sentinel sponsor, and this may impact on my existing Sentinel competencies. (Where applicable)

I understand that I have the right to apply for access to health information held about me, under ‘’subject access rights’’ outlined in The Data Protection Act 1998. Please contact KML OH.

Please note: for directly employed personnel, it is unlawful for the prospective employee to be asked to complete a new starter questionnaire until the job offer has been made in writing.

  • I have understood and accept the declaration.
  • What our clients say

    “  I’m very happy with the service I receive. KML OH is responsive and engaged in the needs of our business and I have confidence in the ability of the staff that I deal with regularly. We’re a small but growing business in the UK and KML can meet our needs at a competitive price.’’

    Sally, HR Director
  • What our clients say

    “ I would happily recommend KML OH to other business; overall I have been exceptionally happy with the service provided. Appointments are booked with ease and the response is swift.’’

    Maria, HR Business Manager
  • What our clients say

    KML OH response time on pre-placement questionnaires is excellent; the outcome is usually sent through to the relevant HR consultant within 48 hours.
    Case management provided by KML OH has also been very good. Again, turnaround time on referral submitted to KML is pleasingly quick. The reports produced in dealing with the referral are comprehensive, detailed and easily understandable. Recommendations are set out in simple, easy to follow terms, which is very welcome.

    Jeremy, HR Business Partner
  • What our clients say

    I have been working with KML since February 2016 and during this time I have found KML OH a pleasure to work with. The service they have provided has been excellent, from both an organisation and testing perspective.
    I have been particularly impressed with their response to emergency requests; they have been very professional and capable to deal with any requests and enquiries.
    As such I would have no hesitation in recommending KML OH to carry out works of this nature to other organisations.

    Lily, Payroll & HR Assistant
  • What our clients say

    What our customers say:
    Very Professional Staff – Never had this with any other company, which is a shame because it was more than expected and reassuring, very good.
    The Clinical Mobile Unit was very clean & tidy, quick checks, great experience, recommended for everyone.

    General, Service Delivery Feedback
  • Workplace illness & injury statistics

    “ Illness - 1.2 million people who worked during the last year were suffering from an illness they believed was caused or made worse by their work. ”

    HSE Health and Safety Statistics Annual Report for Great Britain 2014/15
  • Workplace illness & injury statistics

    “ Illness - A further 0.8 million former workers (who last worked over 12 months ago) were suffering from an illness which was caused or made worse by their past work. ”

    HSE Health and Safety Statistics Annual Report for Great Britain 2014/15
  • Workplace illness & injury statistics

    “ Injuries - 142 workers were killed at work, a rate of 0.46 fatalities per 100,000 workers. ”

    HSE Health and Safety Statistics Annual Report for Great Britain 2014/15
  • Workplace illness & injury statistics

    “ Working days lost - 27.3 million days were lost due to work-related ill health or injury (15 days per case). ”

    HSE Health and Safety Statistics Annual Report for Great Britain 2014/15
  • Workplace illness & injury statistics

    “ days lost - 23.3 million days were lost due to work-related ill health and 4.1 million due to workplace injury. ”

    HSE Health and Safety Statistics Annual Report for Great Britain 2014/15
  • Workplace illness & injury statistics

    “ Cost to Britain - Injuries and new cases of ill health resulting largely from current working conditions cost society an estimated £14.3 billion in 2013/14 (based on 2013 prices). ”

    HSE Health and Safety Statistics Annual Report for Great Britain 2014/15

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