Night-worker questionnaire

It is your right under the Working Time Regulations 1998 (amended 2003) to have regular health assessments whilst a night worker (those who regularly work at least 3 hours between 11pm and 6am). This questionnaire will be used to assess if you have any conditions which may affect your ability to do night work only.

The Questionnaire is CONFIDENTIAL and only the notification of your fitness for employment will be sent to Personnel / Senior Management.

If it is considered necessary, the Doctor may request that he discusses the contents of your questionnaire in more detail either by requesting a consultation in person or over the phone.

Important: Please complete all sections fully and sign declaration, consent and authorisation sections as indicated below.

General Data Protection Regulation (GDPR) 2018 – You or your authorised representative may apply for access to your own occupational health records under the GDPR 2018 by applying in writing to Rockingham Occupational Health Limited. For more information on GDPR see the bottom of the page.

The Access to Medical Reports Act 1988 – This Act does not apply in this situation, as the doctor who examines you is not responsible for your clinical care. He is acting as an independent medical adviser to your current (or prospective) employer. For more information on Access to Medical Records see the bottom of the page.

The questionnaire is powered by JotForm (eu.jotform.com). JotForm is compliant with GDPR (General Data Protection Regulation)., for more information on GDPR see below and for our privacy policy, click here.

General Data Protection Regulation 2018 - Guidance

The information we will be asking you about and will be recording is special category personal data as it will relate to information about your health, medical history and any treatments you have received. We require your written consent before we can accept and process your personal health data.

Staff at Rockingham Occupational Health Ltd may have access to your Occupational Health medical records to enable them to do their jobs. From time to time information may be shared with others involved in your care if it is necessary. Anyone with access to your record is properly trained in confidentiality issues and is governed by both a legal and contractual duty to keep your details private.

In some circumstances we may be required by law to release your details to statutory or other official bodies, for example if a court order is presented, or in the case of public health issues. In other circumstances you may be required to give written consent before information is released – such as for an occupational health assessment, medical reports for insurance, solicitors etc.

To ensure your privacy, we will not disclose information over the telephone or fax unless we are sure that we are talking to you. Information will not be disclosed to family, friends, or spouses unless we have prior written consent, and we do not leave messages with others.

You have the right to see any information we hold about you in your occupational health record. To do so, you can request copies of the information held by emailing us at admin@rockinghamoh.co.uk. If you believe any of the information held is inaccurate or misleading you can request that an amendment is attached to the occupational health record.

WE HAVE A LEGAL DUTY TO KEEP INFORMATION ABOUT YOU CONFIDENTIAL

Access to Medical Reports Act 1988 – Guidance

Before we can apply for a medical report from a doctor we need your consent, and a declaration for this is overleaf. However, you should know that you have certain rights under the Access to Medical Records Act 1988. The main points of the act are as follows:

If you indicate that you do not wish to see the report you are still able to change your mind as long as you write to your doctor requesting to see it before it is sent to us. You have 21 days to contact your doctor to make arrangements to see the report before it is forwarded to us.

If you indicate that you wish to see the report then either your doctor will contact you once it is written, or you need to call your doctor to make arrangements to see the report. Once you have seen the report it will be forwarded to us. If you have not contacted your doctor within 21 days the report will be sent to us.

You can ask your doctor if he / she will amend any part of the report which you consider to be incorrect or misleading. If your doctor is not in agreement, you may attach your comments.

During the six months after we have received your report you may ask your doctor to see a copy. Should you ask for a personal copy of the report the doctor can charge you a reasonable fee to cover the cost.

In some circumstances the doctor may decide, in the interest of your health, or to respect the interest of other persons, that you should not see all or part of the report. The doctor will notify you of this and you will have the right to see any remaining part of the report. If it is the whole of the report which is affected, this will not be given to without your consent.

You can withhold your consent.