Night Worker Screening Form

The purpose of this questionnaire is to assess if you have a health condition which could affect your ability to perform night work and is a requirement of the Working Time Regulations 1998.

If your form indicates any medical condition that may be made worse by night work, you may be invited to discuss this in the strictest of confidence, with your line manager and/or requested to consent to accessing your GP records.

Name *

First

Last

Email *

Date of Birth *

Details of weekly hours of work/ shift pattern *

Diabetes *

Heart or circulatory problems *

Stomach, intestinal or bowel problems, such as ulcers *

Kidney Failure *

Asthma or a chronic chest disorder where night time symptoms may be particularly troublesome *

Epilepsy? (fits/convulsions/blackouts) *

Any anxiety/depression/nervous conditions or any mental health problems which may be affected my night work *

Any problems with vision at night *

A new or expectant mother *

Being treated at present for Infertility *

Any medical condition which causes difficulty sleeping *

Any medical condition requiring medication on a strict timetable *

Any medical condition where the timing of meals is particularly important *

Any other medical condition which may affect ability to work safely at night *

If you have worked at night before, did this cause any ill health *

If you have answered yes to any of the above, please give more details below:

DECLARATION: I consent to the holding and processing of this information and confirm that all medical information given on this form is true and accurate to the best of my knowledge and understand that, if I have given false particulars, I may be subject to disciplinary action. Signed (please print full name): *

First

Last

or I night

Today's Date *