ADVANTAGE ANGELS – NIGHT WORKERS’ HEALTH QUESTIONNAIRE

First Name

Last Name

Position

Branch

Work / Shift Pattern

Start Date

Do you suffer from any of the following conditions, which may be made worse by night work? (Tick all that apply) Do you suffer from any of the following conditions, which may be made worse by night work? (Tick all that apply) Diabetes, requiring insulin injections to a strict timetable A heart condition or circulatory disorder which affects your physical stamina Stomach or intestinal disorder, such as ulcers Any other condition which makes the timing of meals of particular importance A medical condition affecting sleep A chronic chest condition Any medical condition requiring medication to a strict timetable Any other medical condition in which the symptoms get worse at night

Please give further details for any questions that you ticked above.

APPLICANTS DECLARATION: READ AND CONFIRM BEFORE SIGNING APPLICANTS DECLARATION: READ AND CONFIRM BEFORE SIGNING (REQUIRED) I confirm that the information given above is complete and correct, and that I understand that any incomplete, untrue or misleading information, in any material sense, given to Advantage Angels, will entitle them to reject my application, withdraw any work offer made, or dismiss me without notice. (REQUIRED) By my signature, I gave authority to the employer to contact my GP for further details regarding and of the potential health problems which I have declared above. (REQUIRED) If required, I agree to undergo a medical examination in order to assess my suitability for night work (OPTIONAL) I confirm that I have had the opportunity, but I do not wish to have a free health assessment.

Signed:

Date: