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Night Worker Assessment
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
*
Your date of birth
*
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Your job title
*
Assessment
Do you suffer from any of the following
Diabetes
*
Yes
No
Heart or circulatory disorders
*
Yes
No
Stomach or intestinal disorders
*
Yes
No
Difficulty with sleeping
*
Yes
No
Chronic chest disorders
*
Yes
No
A condition requiring medication to a strict timetable
*
Yes
No
Any other health factors that might affect fitness to work
*
Yes
No
As you have answered "yes", please provide details:
*
Validation
I (named above), conform that the above is correct to the best of my knowledge.
Your signature
*
clear
Todays date
*
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Document Version: 1.2
Last reviewed: 14/08/2023
Reviewed by: Kristian H