Social Work Health Assessment
CONFIDENTIAL FOR OCCUPATIONAL HEALTH USE ONLY
Your answers to this questionnaire will be confidential to Occupational Health and will not be disclosed to anyone
without your permission.
The purpose of this assessment is to help determine if you have any health problems or disabilities which may affect
your capability to fulfil the criteria required for social work and social work training. It involves consideration of the
potential for duties to affect any existing health condition or disability you may have as well as such conditions on
your ability to undertake social work training and duties safely and effectively.
We may recommend adjustments or assistance as a result of this assessment to enable you to meet these criteria.
Appropriate advice, in general terms, will be supplied to the School of Health and Social Studies on your suitability for
your course.
Before health clearance is given you may be contacted by Occupational Health for further clarification and may need
to be seen by an Occupational Health Advisor and/or Physician.
Please help us to assist you by completing the questionnaire as fully as possible and signing where indicated.
SURNAME
DATE OF BIRTH
FORENAMES
STUDENT NUMBER
MALE
FEMALE
HOME ADDRESS
EMAIL:
HOME Tel:
MOBILE Tel:
1. Do you have any illness, impairment, disability (physical or psychological) which may affect your ability to
undertake any aspect of the course?
If YES please give details below
YES
NO
2.
Have you ever had any illness, impairment or disability which may have been caused or made worse by work and
could affect your ability to undertake any aspect of the course?
If YES please give details below YES
NO
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3.
Are you having, or waiting for, treatment (including medication) or investigations at present which could affect
your ability to undertake any aspect of the course? YES
NO
If your answer is YES please provide details of the condition, treatment and dates below
4.
Do you think you may need any adjustments or assistance to help you to undertake any aspect of your course
safely and effectively?
If YES please give full details below YES
NO
5.
The Equality Act makes it unlawful to knowingly discriminate against disabled persons in connection with
employment. A person has a disability for the purposes of the law if they have a physical or mental impairment
which has a substantial and long term adverse effect on their ability to carry out normal day-to-day activities.
This includes ‘hidden’ disabilities such as Diabetes and Epilepsy which may be well controlled on treatment and
therefore symptom less, but if left untreated would have a substantial and long-term adverse effect. It also
includes progressive illnesses such as Cancer, HIV and Multiple Sclerosis, from the day of diagnosis onwards.
A "disabled person" means a person who has a disability as defined above. Long term means 12 months or more.
To comply with the law, the School of Health and Social Studies need to know if you consider yourself to have a
disability.
Do you have a disability as defined above?
YES
NO
The Disability Services Team in Student Services at the University of Warwick offers individual advice, guidance and
support to students with Specific Learning Differences/Dyslexia or other sensory impairments, mental health
difficulties, Autistic Spectrum Disorders, unseen disabilities or any other long term condition that affects their
academic life. Students are encouraged to contact the team to discuss their requirements in advance of their course.
Email: disability@warwick.ac.uk
Telephone number: 024 76150641
It is sometimes helpful for Occupational Health to be able to liaise with the Disability Services team to discuss your
requirements. To allow us to do this we will need your permission to share relevant information with the Disability
Services Team, please can you indicate below if you consent.
I DO
/DO NOT
consent to the details of my disability being discussed with the Disability Services Team
(please tick as appropriate)
Signed: .............................................................................................. Date: ...............................
DECLARATION
I declare the answers to the above questions are true and complete to the best of my knowledge and belief.
Signed: .............................................................................................. Date: ...............................
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Please return your completed form to the University of Warwick Occupational Health Services at the address below.
Occupational Health
University Safety & Occupational Health Services,
Westwood House,
Westwood,
The University of Warwick,
Coventry
CV4 7AL
For Occupational Health Use Only
Meets health requirements for
fitness to teach
Meets health requirements with
adjustments detailed below
Does not meet health requirements
for fitness to teach
Recommendations/Comments
Signed (Occupational Health Adviser/Physician )
Date
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