Night Worker Health Questionnaire

The purpose of this health questionnaire is to ensure that your health is not being adversely affected by night work. As a night worker, you are entitled under the Safety, Health and Welfare at Work (General Application) Night Work and Shift Work Regulations 2007 to a health assessment before starting night work and at regular intervals thereafter.

You do not have to avail of the assessment, but your employer must offer it to you.

I consent to undergo health surveillance to protect my health while at work.

I understand that the purpose of the surveillance is to detect any adverse health effects to ensure early intervention and appropriate preventative measures. I consent for a certificate on the outcome of this assessment to be issued to my employer.

Outcomes:

Fit:
You are suitable for Night Work (there is no indication of any medical condition that could affect your ability to work nights)

Defer Fitness Determination - pending doctor’s report:
We need to ask your doctor for corroborative evidence about a medical condition(s) that could affect your ability to work nights

Fit with Conditions:
If the further medical review verifies that you do have a medical condition that impacts your ability to work Nights, we will investigate if it is feasible to modify your work times or work environment to accommodate your medical condition.

Not Fit:
If the further medical review verifies that you do have a medical condition that significantly impacts your ability to work nights and reasonable accommodation for this condition is not possible

I understand that all medical information is confidential and will not be disclosed to my employer without my further written consent.

I understand that all medical information will be filed in accordance with the requirements of the data protection acts.

I authorise the occupational health team to communicate medical information with my GP or other treating doctors if required.

I acknowledge that the answers I give are true and accurate to the best of my knowledge.