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Night Worker Assessment
Who is completing this document?
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Night worker is completing themselves
Office administration team member is completing
The purpose of this questionnaire is to ensure that you are suited to working at night. All the information you provide will be kept confidential
Details
Your name
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Your date of birth
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Your job title
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Night workers name
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Night workers date of birth
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Night workers job title
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Assessment
Do you suffer from any of the following:
Does the night worker suffer from any of the following:
Diabetes
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Yes
No
Heart or circulatory disorders
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Yes
No
Stomach or intestinal disorders
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Yes
No
Difficulty with sleeping
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Yes
No
Chronic chest disorders
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Yes
No
A condition requiring medication to a strict timetable
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Yes
No
Any other health factors that might affect fitness to work
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Yes
No
As you have answered "yes", please provide details:
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Validation
I (named above), conform that the above is correct to the best of my knowledge.
Your signature
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clear
Todays date
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Administrators name:
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Administrators job title:
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Date completing:
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Completed by:
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Telephone conversation:
Face to face meeting:
Why is the night worker not completing this form themselves?
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Administrators signature
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clear
Document Version: 1.4
Last reviewed: 09/09/2024
Reviewed by: Kristian H