Night Workers Health Assessment Questionnaire by Business Gateway
The Business Gateway Night Worker Health Assessment Questionnaire ensures compliance with the Working Time Regulations 1998 by assessing whether employees are medically fit to undertake night work. It helps employers safeguard staff wellbeing and manage workplace health risks effectively while maintaining confidentiality through occupational health oversight.
Sample Working Time Regulations 1998 Health Assessment Questionnaire – Night Workers
A night worker is an employee who is scheduled to work at least three hours of his/her daily working time during night time on the majority of days on which he/she is scheduled to work. Night time is defined as the period between 11 pm and 6 am.
Night workers are entitled to a voluntary health assessment to check whether they are fit for the work required. Very few health problems will prevent people being able to work at night, and where there is a medical problem that could be relevant, it will almost always be possible for the person to be able to work during night hours with suitable modifications to their treatment programme.
The purpose of the questionnaire is to ask whether you have any health problem that could be affected by night work, so that where necessary an appropriate medical review can be arranged. The questionnaire will be confidential to the Company’s Occupational Health Adviser (It is advisable to identify a local Occupational Health Adviser – or to use the area NHS Occupational Health Service) but a report on your fitness will be provided to your manager who is responsible for work assignments and for the arrangements for health and safety at work.
Please complete the form and tick the appropriate box for the questions listed; if you have any other condition that you believe should be considered, please write brief details at the bottom of the page or continue on a separate sheet of paper.
Name: [employee name]
Address: [employee address]
Manager: [manager name]
Working Time Regulations 1998 Health Assessment Questionnaire – Night Workers
Yes | No | |
Have you had any medical problem in the past that has prevented you from working at night? | ||
Are you diabetic? | ||
Are you subject to angina, or other heart problems that may affect your fitness? | ||
Have you had duodenal or stomach ulcers in the past, or are you under treatment for those at present? | ||
Have you had any continuing bowel problem, for instance following major surgery? | ||
Do you have any chronic chest problem such as asthma, emphysema or bronchiectasis? | ||
Do you have any disability affecting mobility that will cause difficulties in arranging night work? | ||
Do you have any recurrent or continuing sleep disturbance requiring medical advice? | ||
Are you having specialist care requiring your attendance at hospital clinics for treatment? | ||
Do you have any other health problem that affects your fitness for night work? | ||
Are you taking any medication to a strict timetable? | ||
Please give the names of any prescribed medications that you take regularly: | [names of prescribed medications taken regularly] | |
Please give any further details that you would like to bring to our attention. | [any further details] |
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