1
Occupational Health
Department
OCCUPATIONAL HEALTH DEPARTMENT
LOCAL PROCEDURE
Title of procedure
Pre-placement health and disability
assessment - Staff
Date of issue
Version
November 2011 V1
May 2012 Version 2
Author
Sarah Purdy
Approved by
Controlled document
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CONTENTS
Page
1.
2.
3.
4.
5.
6.
7.
Purpose
Scope
Definitions
Procedure
Outcomes and performance measures
References
Appendices
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Pre-placement health and disability assessment - staff
1. PURPOSE
1.1 This procedure describes how Pre-Placement Assessments are to be undertaken by the
Occupational Health team at the University of Hull, and how the findings of pre-placement
assessment are communicated to the recruiting management team.
The purpose of pre-placement assessment is:
Identify health and disability needs that require support
Assess ‘fitness for task’
Identify the need for baseline health surveillance.
Pre-placement assessment undertaken as set out in this procedure is intended to help support the
University of Hull discharge some of its obligations under the Equality Act 2010.
2. SCOPE
2.1 The procedure applies to all employed staff of the University of Hull and is implemented by staff
in the Occupational Health Department.
2.2 The procedure only pertains to the Occupational Health elements of the process and specifically
covers activity from the arrival of the questionnaire into the department. It does not cover any of
the activities undertaken by Human Resources.
3. DEFINITIONS
3.1 Employee – means an employee of the University of Hull, this can for pre-placement purposes be
an individual who has been offered a post or an existing employee transferring to a new post.
3.2 Staff – as above for employee
3.3 Occupational Health (OH) Practitioner – can be an OH Technician, OH Nurse, OH Advisor, OH
Physician
3.4 Pre-placement health questionnaire/Questionnaire – the health and disability questionnaire sent
out by Human Resources to an individual who has been selected for a new post at the University
3.5 A pre-placement health assessment is a health and disability assessment of a new employee, or
an existing employee moving to a new post, previously often referred to as pre-employment
assessment
4. PROCEDURE
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4.1 The pre-placement health questionnaire (appendix 1 and 2) usually arrives in the department as
a paper copy; if it arrives electronically the questionnaire should be printed. The questionnaire
should be date stamped, and an entry made on SIMS to notify Human Resources (HR) that the
Occupational Health (OH) department has received the questionnaire. An Occupational health file
should be created (please refer to the OH department procedure for creating and maintaining OH
records) unless an OH record already exists. The questionnaire and the ‘health questionnaire paper
screening checklist’ completed as far as possible (appendix 5) should be placed in the OH records.
The health questionnaire should be looked through to ensure all sections are complete. If any
sections from page 2 onwards are incomplete the questionnaire should be returned to the individual
with compliments slip attached detailing which sections are incomplete and requesting the
questionnaire is fully completed and returned. A postage paid, addressed envelope should also be
included. If the details on page 1 are incomplete then the questionnaire cannot be returned to
Human Resources as medical confidentiality would be breached. In this instance the relevant HR
Assistant should be contacted and asked to provide the required information – they may need to
liaise with the recruiting manager to obtain this information. Only once all the information is
available can the questionnaire be screened. Should the above situation occur this should be
documented in the OH record. If the questionnaire is returned to the individual HR and the
recruiting manager should be informed
4.2. The OH record should then be placed in the pre-placement folder in the filing cabinet and the
pre-placement total amended on the white board.
4.3 At the next available opportunity the records in the pre-placement folder will be paper screened
by an OH practitioner. Please refer to appendix 6 for OH Technician paper screening process.
4.4 If the pre-placement assessment screening process can be completed on paper i.e. no further
information is required then the ‘health questionnaire paper screening checklist (appendix 5) should
be completed, the ‘Report of health: pre-placement assessment’ (appendix 4) should be completed
and the ‘report of health’ should be sent electronically to the recruiting manager – named on the
questionnaire and copied to the HR Advisor named on the questionnaire and relevant HR assistant
(all details should be on page one of the questionnaire). A copy of this report should be printed
along with the e-mail sending the report; these should be filed in the OH record. The individual
should be sent Display Screen Equipment (DSE) information by e-mail or placed on the pending list
for this to be sent if their start date is not imminent. The relevant section of the OH database should
be completed and the records filed.
4.5 If the pre-placement health screening cannot be completed without additional information the
OH practitioner dealing with the case should decide upon the next action required, this could be
anyone of the following:





Undertake a telephone assessment of the client
Undertake a face to face assessment with the client
Obtain a medical report
Seek an OH Physician opinion by discussing the case with the OH physician
Arranging for the individual to be assessed by and an opinion sought from the OH Physician
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It may be that one of the above activities provides sufficient information for the OH Practitioner to
complete the pre-placement screening process. It may however require more than one of the above
activities to be undertaken before the process can be completed. In rare cases all the above
activities may need to be undertaken before an opinion can be offered to the management team. At
any stage in the process if an OH practitioner has any anxiety or uncertainty about the management
of a case they should discuss and share the case with another practitioner in the department. At
each stage the ‘Health questionnaire paper screening checklist’ (appendix 5) should be updated. The
following section 4.6 to 4.10 have been set out in order however in the management of a case this
order does not need to be followed and any of the further actions can be undertaken in any order.
Once the next action has been decided an ‘interim statement: pre-placement’ (appendix 3) should
be completed and sent to the management team this should be sent within 1 week of screening; a
copy printed and filed in the OH records.
4.6 Telephone assessment of client; in many instances a telephone assessment of an individual at
the pre-placement stage will provide further detail which will allow the case to be processed. Using
the contact details on the pre-placement questionnaire the individual should be contacted by phone.
If they are unavailable and an answer-phone facility is available a message should be left asking
them to contact the OH department in relation to the health questionnaire. If there is no answerphone facility a further call should be made within the following couple of days. Alternatively an email may be sent requesting the individual to call the OH department. If no response is received
after two attempts to contact the individual and a period of one week has passed since the first
contact was made then the management team should be notified and instruction awaited.
Management of the case should be suspended and, the ‘health questionnaire paper screening
checklist’ (appendix 5) updated. If telephone contact is successful either the case can be managed
with the information provided and the process completed or further action is required. If the
information is sufficient then the process should be completed as outlined in section 4.4 If further
action is required then the next action required as set out in section 4.5 should be decided upon.
4.7 Face to face assessment with a client; if face to face assessment is required the individual should
be contacted by letter to their postal address or e-mail as per the OH appointment letter - please
refer to the OH procedure on case management. In some cases it may be more appropriate to
contact the individual by phone advising of the requirement for an appointment and details of the
appointment. This can be supported by a letter or e-mail. If two appointments are offered and there
is a failure to attend on two occasions, management of the case should be suspended and the
management team advised. Their instruction should be awaited. Please see appendix 10 for
guidance on face to face pre-placement assessment with a suggested framework .Following face to
face assessment of the individual if enough information is available for the case to be completed
then the process set out in section 4.4 should be followed. If further action is required then the next
action as set out in section 4.5 should be decided upon.
4.8 Obtain a medical report; during the pre-placement assessment process it may be felt necessary
to obtain a medical report. A medical report can only be obtained with the written consent of the
individual. The pre-placement health questionnaire asks for consent to be given or declined see
section 5b of appendix 1 and 2. This consent only remains valid for a period of up to 6 months. If
consent is given a medical report may be obtained from the health professionals detailed on the
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consent. The OH local operating procedure for case management should be referred to. If consent
has been declined a report cannot be obtained. The management team should be advised that a
medical report is required in order that a health opinion can be offered but in the absence of being
able to obtain a report an opinion can only be offered based upon the information available. Upon
receipt of a medical report this may provide sufficient information to process the case and process
outlined in section 4.4 should be followed. If the medical report does not provide sufficient
information then further action as set out in section 4.5 should be decided upon.
4.9 Obtain an OH Physician opinion; during the pre-placement process it may be felt necessary to
obtain an opinion on the case from the OH Physician. This involves the case detail being discussed
with the OHP either face to face or over the phone, and their advice being sought. If this provides
sufficient information for the case to be processed then section 4.4 should be referred to. If this
does not provide sufficient information then further action as set out in section 4.5 should be
decided upon.
4.10 OH Physician assessment; it may be felt that a case needs to be referred to the OH Physician for
assessment and opinion. This referral can be made at any stage of the process. The individual should
be contacted this can be by phone, letter or e-mail advising them that they have been referred to
the OH Physician and the providing details of their appointment. If the individual declines to attend
an OH Physician appointment or fails to attend on two occasions then management of the case
should be suspended and the management team advised. Their instruction should be awaited.
Following assessment the OH Physician will write to the management team, section 4.4 should be
referred to and followed. Consideration however should be given to provision of the ‘Report of
health: pre-placement assessment (appendix 4). If the OH Physician report covers all the detail
contained in the ‘report of health’ then duplication of information should be avoided. If however it is
felt that provision of this report is not duplication of information then it should be sent.
4.11 In addition to the above where an individual will be undertaking specific tasks as part of their
role consideration should be given as to the need for pre-placement health assessment below is a
list of activities that are likely to require a health assessment (this is not an exhaustive list):








Work at height
Work in a confined space
Working in a health care setting
Food handling
Working with sewage
Working in extremes of temperatures
Driving a University vehicle on University business
Undertaking vocational diving
Please note as at the time writing this procedure measures are not in place to undertake all the
above health assessments
4.12 In addition to the above consideration should be given to identifying individuals from the preplacement information that will be working with specific health hazards who may require health
surveillance (this is not an exhaustive list):
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




Working with respiratory sensitizers
Working with skin sensitizers
Working with high levels of noise
Work involving exposure to hand arm vibration
Please note as at the time writing this procedure measures are not in place to undertake all
the above health surveillance
4.12 Pre-placement assessment of staff who will be working for the Post Graduate Medical Institute
(PGMI), in addition to the above staff working for PGMI should at the end of the assessment be
asked to complete in conjunction with the OH practitioner the’ Occupational Health report with
consent – following pre-placement assessment of clinical practitioners Post Graduate Medical
Institute’ form (appendix 8). The rational for this is that although employee’s of the University of Hull
and therefore the University has responsibility to assess at the pre-placement stage this group of
staff will work predominantly and often exclusively in an NHS Trust or other Healthcare setting. The
place of work may require to know that these staff have been assessed and ‘cleared’ to work as a
health care worker in order to discharge their responsibilities; they may wish to know if clearance
has been given for Exposure Prone Procedures (EPP) or not, they may wish to have details of their
immunisation history. Some of this information cannot be divulged without the individuals consent.
It is therefore felt to be prudent to discuss these issues with this group of staff and request their
written consent to divulge appropriate information to relevant parties. Disclosure of this information
would be to Occupational Health Department staff, who would treat as medically confidential.
4.13 Academic cardiology; for staff who will be observing and/or working in academic cardiology a
letter (appendix 9) should be sent to the individual with a ‘ Confidential pre-placement
questionnaire health care worker ‘ (appendix 1). Upon return of the completed health questionnaire
the pre-placement assessment procedure as outlined above should be followed from section 4.7
onwards. Upon completion of the screening process the ‘report of health pre-placement
assessment’ (appendix 4) should then be sent to the Assistant to the Divisional Manager – Division of
Cardiovascular & Respiratory Studies.
4.13 Individuals who are identified from the pre-placement information as potentially having
support needs. If an individual has divulged health or disability information that leads the OH
practitioner to believe that support at work may be needed or they have specifically identified that
they have support needs the OH practitioner will contact the individual.
4.14 Higher Education Statistics Agency (HESA) data – Where the information contained within the
questionnaire indicates that an individual has a health issue or disability that may deem them as
disabled within the terms of the Equality Act 2010 (please refer to section 2c,d&e of appendix 1 and
2), and they have consented then the relevant section of the HR database should be completed. This
data is for statistical purposes only and is anonymous.
4.15 Please note that there is available a manager’s information sheet (appendix 11). This sheet has
been designed with the intention of the HR team issuing to the recruiting manager at the point at
which they ask the recruiting manager to complete/provide information for page 1 of the preplacement questionnaire. This element is out-with this procedure. The information sheet however
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may be used for other reasons such as a manager making a generic enquiry about the pre-placement
process.
5.OUTCOMES AND PERFORMANCE MEASURES
5.1 That all pre-placement assessments are undertaken within the time frame set out within the OH
dept KPI document and to the criteria set out in relevant policies and procedures.
Performance measure will include measurement of activity against KPI’s, clinical process audit of
pre-placement screening and monitoring of level of complaints received.
6. REFERENCES
Preparing and Recording Occupational Health Records Procedure
X drive/Occupational Health Folder/Quality/Policies
Case Management Procedure for Management Referrals
X drive/Occupational Health Folder/Quality/Policies
Occupational Health Department Key Performance Indicators
X drive/Occupational Health Folder/Quality /KPI’s
7. APPENDICES
Appendix 1 – Confidential pre-placement health questionnaire Health care worker
Appendix 2 – Confidential pre-placement health questionnaire non-health care worker
Appendix 3 – Interim statement: pre-placement assessment
Appendix 4 –Report of health: Pre-placement assessment
Appendix 5 – Health questionnaire paper screening checklist
Appendix 6 - Process for ‘first pass’ pre-placement assessment by OH technician
Appendix 7 -OH Technician report of health: pre-placement assessment
Appendix 8 - Occupational Health report with consent – following pre-placement assessment of
clinical practitioners Post Graduate Medical Institute
Appendix 9 – Letter – staff working in academic cardiology observing clinical practice
Appendix 10 – Pre-placement assessment guidance
Appendix 11 – Managers information sheet – pre-placement assesment
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Appendix 1
Confidential Pre-placement Health Questionnaire
Health care worker
Section 1a. To be completed by the appointing person
Name:
Date of birth:
Job applied for:
Department:
Start date:
Job profile:
Expected contract end date:
Section 1b. To be completed by the appointing person in consultation with the head of department or
section
The job involves:
Yes
No
Details
 Lifting weights above 10kg
 Vocational driving -please provide details
 Work at height
 Work in a confined space
 Working with a VDU
 Genetic manipulation
 Exposure prone medical procedures
 Night work
 Food handling
 Working with equipment that produces hand
arm vibration
 Working with noise above 80Db(A)
 Other – please specify
There is potential exposure to:
 Eye injury
 Excessive dust
 Fumes -please provide details
 Solvents
 Ionising radiation
 Lasers
 Carcinogens
 Blood and body fluids/tissues
 Cytotoxic agents
 Anaesthetic gases
 Respiratory sensitizers or skin sensitizers
The job involves contact with:
 Patients
 Children
 Food
 Animals
Any other relevant factors:
Name of appointing person
completing section 1
.....................................
Name of head of
Department/section
Signature
Signature
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Name: ..............................................................
Date of Birth:
........................................
Section 2.
The questionnaire below when completed will be reviewed by a member of the Occupational Health
team. A health opinion on suitability for work including any specific tasks will be given to the
appointing manager and HR Advisor. This questionnaire will be used by the team to help assess your
fitness for work and consider what if any support may be required during your employment.
Please return this completed questionnaire prior to the commencement of your role to the:
Occupational Health Department
University of Hull
Cottingham Road
Hull
HU6 7RX
Complete all relevant sections and provide details where appropriate. There is additional space at the
end of the form where there is insufficient space in the box provided. At the end you will be asked to
sign a declaration, indicating that you have answered the questions truthfully and to the best of your
knowledge.
Section 2a. To be completed by the individual
Surname............................................................ First Name(s).............................................................
Title
Prof/Dr/Mrs/Miss/Ms/Mr/Other......................................
Date of birth.....................................
Previous surname................................................................................................
Male/Female
Address...................................................................................................................................................
................................................................................................................................................................
....................................................................................................
Post Code........................................
Contact Telephone Number(s)................................................................................................................
E-mail address........................................................................................................................................
National Insurance number.............................................................Place of birth...................................
Section 2b. To be completed by the individual
Have you previously been employed by the
University of Hull?
If yes please give dates
Are you currently pregnant or breastfeeding?
If yes please provide more detail
Please briefly list previous jobs in the last 10
years
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Yes/No
Yes/No
(Continue on separate page if necessary)
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Name: ..............................................................
Date of Birth:
........................................
Section 2b. continued
In your previous employment have you ever been
exposed to any hazards?
If yes please detail
Yes/No
If yes please detail any monitoring performed
Hazard:
Monitoring:
Section 2c. To be completed by the individual
Disability – Please refer to the information in appendix 1 before completing section 2c, 2d and 2e
Yes
No
Yes
No
Yes
No
Do you consider yourself to have a disability?
If you have answered ‘yes’ to section 2c please complete section 2d
Section 2d.
Do you have?
A specific learning disability (such as dyslexia or dyspraxia)
General learning disability (such as Down’s syndrome)
Cognitive impairment ( such as autistic spectrum disorder or suffered head injury)
Chronic health issue ( such as HIV, diabetes, or epilepsy)
Mental health condition ( such as depression or schizophrenia)
Physical impairment or mobility issue
Hearing impairment
Visual impairment
Other type of disability – please provide further detail
Section 2d. continued
Would you like the Occupational Health team to contact you to discuss support
needs?
Section 2e.
It is a requirement of the Data Protection Act that you give explicit consent for ‘sensitive’ data
such as disability to be retained as part of the University’s computerised record. This
information will be included in a confidential statistical record. This will only be used in
connection with the fulfilment, monitoring and development of the University’s equality and
diversity policies.
I DO / DO NOT (please delete as applicable) give consent for this data to be retained as set out
above
Signed
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Section 3. To be completed by the individual
Do you have or have you ever had
Yes
No
Details (If answered yes)
Mental health issues, depression, anxiety,
psychosis, self harmed or have an eating
disorder?
Psychiatric or psychological treatment or
counselling?
Disorders affecting back, neck, shoulders,
hand, arm knees, hips, arthritis?
Gastric tract disorders, bowel or stomach
problems, hernia or rupture?
Heart or circulatory problems, raised blood
pressure, angina, chest pain palpitations?
A urinary tract disorder, kidney or bladder
problem?
Breathing problems, asthma COPD, bronchitis,
persistent cough, chest disease?
Visual problems, ear, nose or throat problems?
Skin problems, eczema, psoriasis, dermatitis?
Chronic fatigue?
Disorders of the nervous system, epilepsy,
fainting, balance problems, dizziness, migraine
or frequent headaches?
Diabetes or other endocrine disorders?
Known allergies, including latex?
Any impairment affecting communication?
Drug or alcohol misuse?
Are you attending hospital or your GP or
receiving any medical treatment at present?
Do you take any medication, have injections or
use any ointments regularly?
Have you had any operations, serious
accidents or illnesses not previously
mentioned?
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Name: ..............................................................
Section 4.
4a)To be completed by the individual
Have you had any of the
following infectious diseases?
Yes
No
Date of Birth:
Don’t
Know
........................................
Details
Measles
Mumps
Rubella (German Measles)
Chicken Pox
Whooping cough
Diphtheria
Hepatitis
Typhoid or paratyphoid
Have you ever had tuberculosis
(TB), do you have a family history
of TB or close contact with anyone
suffering from TB?
Please indicate in which country your immunisations were given ...................................................
4b)
Immunisation history
(To be completed by the individual’s GP practice and/or Occupational Health department)
Yes
No
Date
Comment
TB skin test (Heaf, Mantoux)
BCG
Hep B 1
Hep B 2
Hep B 3
Hep B surface antibody
MMR1
MMR 2
Rubella
Rubella titre level
Varicella vaccination
Varicella immunity (blood test)
Hepatitis B surface antigen
HIV
Hepatitis C
Other –please specify
Note: If the GP practice or OH dept cannot provide the above information this form should still be
signed and stamped by the GP Practice/OH dept.
Comments:
Signature of practitioner.................................................................................................
Title ............................................................................... Date........................................
Practice/Department stamp:
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Name: ..............................................................
Date of Birth:
........................................
Section 5. To be completed by the individual
5a) Declaration
In signing this questionnaire you are confirming that all the information is true to the best of your
knowledge. You accept that if it is subsequently shown that relevant medical information has not
been disclosed or has been misleading or false, in some circumstances you may reasonably be
regarded as unfit for employment.
The University of Hull complies with data protection legislation. In signing this declaration you confirm
that you have given your consent to the University of Hull to process your personal information with
respect to your employment. This form will form part of your Occupational health record, which will
be retained by the University for at least the period of your employment.
It may be required that you attend for health screening or medical assessment in relation to the
health assessment. In signing this declaration you confirm your consent to undergo further medical
assessment in relation to the health assessment process.
Dependent upon the responses above the University of Hull may require further medical information
via a report. Further medical information can only be sought with written informed consent from
yourself. Please see box below.
Signature................................................................................
Date................................................
5b) Consent
Please read and retain information in section 6 below before completing this section
I understand my rights under the Access to Medical Reports Act 1988 and have read the summary of
principal rights. This consent will remain valid for a period of up to six months from signing. A copy of
this consent shall have the validity of the original.
*Please delete whichever is not applicable
*I consent to a medical report being obtained OR I do not consent to a medical report being obtained
*I wish to see the report before it is sent OR I do not wish to see the report before it is sent
Name and contact details of GP from whom a report may be requested
Name and contact details of specialist or health care professional from whom a report may be
requested
Signature................................................................................
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Additional information (please attach further sheets as required, with your name and date of
birth on)
Section 6. To be retained by the individual
Summary of your principal rights under the access to Medical Reports Act 1988
This is a summary of your principal rights under the above act which is concerned with report
provided by a medical practitioner who is or has been responsible for your clinical care.
Option A: You may withhold your consent to an application for the report from a medical practitioner
but should note that the inability to obtain up-to-date medical information may affect decisions made
about your suitability for work placements by the University.
Option B: You may consent to the application for a report, but indicate your wish to see the report
before it is supplied. You must make your own arrangements to see the report it will not be
automatically sent to you.
The medical practitioner will be informed that you wish to see the report and will allow 21 days for you
to view and approve it before it is sent to the Occupational Health Department. If the Medical
Practitioner has not heard from you in writing within 21 days of the application for the report being
made he/she will assume that you do not wish to see the report and that you consent to it being
supplied. When you see the report if there is anything in it which you consider incorrect or misleading
you can request (this must be in writing) that the medical practitioner amend the report. He/she is not
obliged to do so. If the medical practitioner refuses to amend it you may:
1) Withdraw consent for the report to be issued
2) Ask the medical practitioner to attach to the report a statement setting out your own views
3) Agree to the report being issued unchanged
Note: The Medical Practitioner is not obliged to show you any parts of the report which they believe
might cause serious harm to your physical or mental health or that of others, or which would reveal
information about a third party or the identity of a third party who has supplied the practitioner with
information about your health unless the third party also consents. In those circumstances the Medical
Practitioner will also inform you. Your access to the report will be appropriately limited.
Option C: You may consent to the application for the report but indicate that you do not wish to see
the report before it is supplied. Should you change your mind after the application is made and notify
the medical practitioner in writing they should allow 21 days to elapse after such notification so that
you may arrange to have access to the report (if the report has not already been supplied before you
changed your mind).
Option D: Whether or not you decide to seek access to the report before it is supplied, you have the
right to seek access to it from the medical practitioner at any time up to 6 months after it was supplied.
Information acquired will be included in the student health record in accordance with the Data
Protection Act 1998.
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Appendix 1
Disability disclosure – To be retained by the individual
Section 2c, 2e and 2d of this questionnaire pertain to disability. All information provided will be held
confidentially and treated as medically confidential.
Why is this information being collected?
There are three reasons to collect this information:



Each year all universities have to provide statistics about their staff to the Higher Education
Statistics Agency (HESA). These statistics help to indicate what needs to be done to
encourage more people with disabilities to work in the sector.
To help the university understand how well it is doing in recruiting and supporting disabled
staff. Without an idea of the numbers of disabled staff, it is difficult to know whether our
policies and practices are really providing equal opportunities for disabled people.
The third and most important reason is to provide you with information about the types of
support available to disabled people working at the university.
What does the term disability mean?
The term ‘disabled’ covers a wide range of impairments and health conditions. The definition within
the Equality Act 2010 states ‘a physical or mental impairment which has a substantial and long term
adverse effect on the ability to carry out normal day to day activities.
It would be impossible to provide an exhaustive list but conditions such as arthritis, diabetes,
depression, dyslexia, multiple sclerosis and cancer may be considered a disability
So what now?
If you have a disability you may feel that you have support needs either now or in the future. There is
a range of support available to disabled staff at the university.
Occupational Health department
Staff in the OH department support staff with disabilities. Your support needs can be
discussed with them and advice offered to both you and your manager on making changes;
this may include assistive software, provision in equipment, support workers, modification to
working arrangements. If you would like to speak to a member of the OH team they can be
contacted on telephone number 01482 466011 or by e-mail at occupationalhealth@hull.co.uk
Equality and Diversity Advisor
The Equality and Diversity Advisor can provide advice, information and training on all equality
and diversity issues which includes disability. They can be contacted on 01482 466333 or by
e-mail at a.mwangi@hull.ac.uk
Disabled staff network
The university has a network of disabled staff who provide mutual support and advice to one
another. The network can be accessed by contacting the Equality and Diversity Advisor as
above.
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Appendix 2
Confidential Pre-placement Health Questionnaire
Non-health care worker
Section 1a. To be completed by the appointing person
Name:
Date of birth:
Job applied for:
Department:
Start date:
Job profile:
Expected contract end date:
Section 1b. To be completed by the appointing person in consultation with the head of department or
section
The job involves:
Yes
No
Details
 Lifting weights above 10kg
 Vocational driving -please provide details
 Vocational diving
 Work at height
 Work in a confined space
 Working with a VDU
 Genetic manipulation
 Exposure prone medical procedures
 Night work
 Food handling
 Working with equipment that produces hand
arm vibration
 Working with noise above 80Db(A)
 Other – please specify
There is potential exposure to:
 Eye injury
 Excessive dust
 Fumes -please provide details
 Solvents
 Ionising radiation
 Lasers
 Carcinogens
 Blood and body fluids/tissues
 Respiratory sensitisers
 Skin sensitizers
The job involves contact with:
 Patients
 Children
 Food
 Animals
Any other relevant factors:
Name of appointing person
completing section 1
.....................................
Name of head of
Department/section
Signature
Signature
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......................................
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Name: ..............................................................
Date of Birth:
........................................
Section 2.
The questionnaire below when completed will be reviewed by a member of the Occupational Health
team. A report of health giving a health opinion on fitness for work including any specific tasks will be
given to the appointing manager and HR Advisor. This questionnaire will be used by the team to help
assess your fitness for work and consider what if any support may be required during your
employment.
Please return this completed questionnaire prior to the commencement of your role to the:
Occupational Health Department
University of Hull
Cottingham Road
Hull
HU6 7RX
Complete all relevant sections and provide details where appropriate. There is additional space at the
end of the form where there is insufficient space in the box provided. At the end you will be asked to
sign a declaration, indicating that you have answered the questions truthfully and to the best of your
knowledge.
Section 2a. To be completed by the individual
Surname............................................................ First Name(s).............................................................
Title
Prof/Dr/Mrs/Miss/Ms/Mr/Other......................................
Date of birth.....................................
Previous surname................................................................................................
Male/Female
Address...................................................................................................................................................
................................................................................................................................................................
....................................................................................................
Post Code........................................
Contact Telephone Number(s)................................................................................................................
E-mail address........................................................................................................................................
National Insurance number.....................................................................................................................
Section 2b. To be completed by the individual
Have you previously been employed by the
University of Hull?
If yes please give dates
Are you currently pregnant or breastfeeding?
If yes please provide more detail
Please briefly list previous jobs in the last 10
years
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Yes/No
Yes/No
(Continue on separate page if necessary)
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Name: ..............................................................
Date of Birth:
........................................
Section 2b. continued
In your previous employment have you ever been
exposed to any hazards?
If yes please detail
Yes/No
If yes please detail any monitoring performed
Hazard:
Monitoring:
Section 2c. To be completed by the individual
Disability – Please refer to the information in appendix 1 before completing section 2c, 2d and 2e
Yes
No
Yes
No
Yes
No
Do you consider yourself to have a disability?
If you have answered ‘yes’ to section 2c please complete section 2d
Section 2d.
Do you have?
A specific learning disability (such as dyslexia or dyspraxia)
General learning disability (such as Down’s syndrome)
Cognitive impairment ( such as autistic spectrum disorder or suffered head injury)
Chronic health issue ( such as HIV, diabetes, or epilepsy)
Mental health condition ( such as depression or schizophrenia)
Physical impairment or mobility issue
Hearing impairment
Visual impairment
Other type of disability – please provide further detail
Section 2d. continued
Would you like the Occupational Health team to contact you to discuss support
needs?
Section 2e.
It is a requirement of the Data Protection Act that you give explicit consent for ‘sensitive’ data
such as disability to be retained as part of the University’s computerised record. This
information will be included in a confidential statistical record. This will only be used in
connection with the fulfilment, monitoring and development of the University’s equality and
diversity policies.
I DO / DO NOT (please delete as applicable) give consent for this data to be retained as set out
above
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Signed
Date
Section 3. To be completed by the individual
Do you have or have you ever had
Yes
No
Details (If answered yes)
Mental health issues, depression, anxiety,
psychosis, self harmed or have an eating
disorder?
Psychiatric or psychological treatment or
counselling?
Disorders affecting back, neck, shoulders,
hand, arm, knees, hips, arthritis?
Gastric tract disorders, bowel or stomach
problems, hernia or rupture?
Heart or circulatory problems, raised blood
pressure, angina, chest pain palpitations?
A urinary tract disorder, kidney or bladder
problem?
Breathing problems, asthma COPD, bronchitis,
persistent cough, chest disease?
Visual problems, ear, nose or throat problems?
Skin problems, eczema, psoriasis, dermatitis?
Chronic Fatigue?
Disorders of the nervous system, epilepsy,
fainting, balance problems, dizziness, migraine
or frequent headaches?
Diabetes or other endocrine disorders?
Known allergies, including latex?
Any impairment affecting communication?
Drug or alcohol misuse?
Are you attending hospital or your GP or
receiving any medical treatment at present?
Do you take any medication, have injections or
use any ointments regularly?
Have you had any operations, serious
accidents or illnesses not previously
mentioned?
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Name: ..............................................................
Date of Birth:
........................................
Section 4. To be completed only by individuals who undertake a role involving food handling.
Yes
No
Details
Have you ever had typhoid or paratyphoid fever?
Are you suffering from any of the following?







Skin rash or skin conditions
Boils
Diarrhoea and /or vomiting now or within
the last seven days
Discharge from the eye
Discharge from the ear
Discharge from the nose
Problems with teeth or gums
Have you ever lived abroad?
If yes please detail which country/s and applicable
dates
Have you travelled abroad recently (within the last
month)?
If Yes please detail which country/s and
applicable dates
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Name: ..............................................................
Date of Birth:
........................................
Section 5. To be completed by the individual
5a) Declaration
In signing this questionnaire you are confirming that all the information is true to the best of your
knowledge. You accept that if it is subsequently shown that relevant medical information has not
been disclosed or has been misleading or false, in some circumstances you may reasonably be
regarded as unfit for employment.
The University of Hull complies with data protection legislation. In signing this declaration you confirm
that you have given your consent to the University of Hull to process your personal information with
respect to your employment. This form will form part of your Occupational health record, which will
be retained by the University for at least the period of your employment.
It may be required that you attend for health screening or medical assessment in relation to the
health assessment. In signing this declaration you confirm your consent to undergo further medical
assessment in relation to the health assessment process.
Dependent upon the responses above the University of Hull may require further medical information
via a report. Further medical information can only be sought with written informed consent from
yourself. Please see box below.
Signature................................................................................
Date................................................
5b) Consent
Please read and retain information in section 6 below before completing this section
I understand my rights under the Access to Medical Reports Act 1988 and have read the summary of
principal rights. This consent will remain valid for a period of up to six months from signing. A copy of
this consent shall have the validity of the original.
*Please delete whichever is not applicable
*I consent to a medical report being obtained OR I do not consent to a medical report being obtained
*I wish to see the report before it is sent OR I do not wish to see the report before it is sent
Name and contact details of GP from whom a report may be requested
Name and contact details of specialist or health care professional from whom a report may be
requested
Signature................................................................................
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Additional information (please attach further sheets as required, with your name and date of
birth on)
Section 6. To be retained by the individual
Summary of your principal rights under the access to Medical Reports Act 1988
This is a summary of your principal rights under the above act which is concerned with report
provided by a medical practitioner who is or has been responsible for your clinical care.
Option A: You may withhold your consent to an application for the report from a medical practitioner
but should note that the inability to obtain up-to-date medical information may affect decisions made
about your suitability for work placements by the University.
Option B: You may consent to the application for a report, but indicate your wish to see the report
before it is supplied. You must make your own arrangements to see the report it will not be
automatically sent to you.
The medical practitioner will be informed that you wish to see the report and will allow 21 days for you
to view and approve it before it is sent to the Occupational Health Department. If the Medical
Practitioner has not heard from you in writing within 21 days of the application for the report being
made he/she will assume that you do not wish to see the report and that you consent to it being
supplied. When you see the report if there is anything in it which you consider incorrect or misleading
you can request (this must be in writing) that the medical practitioner amend the report. He/she is not
obliged to do so. If the medical practitioner refuses to amend it you may:
4) Withdraw consent for the report to be issued
5) Ask the medical practitioner to attach to the report a statement setting out your own views
6) Agree to the report being issued unchanged
Note: The Medical Practitioner is not obliged to show you any parts of the report which they believe
might cause serious harm to your physical or mental health or that of others, or which would reveal
information about a third party or the identity of a third party who has supplied the practitioner with
information about your health unless the third party also consents. In those circumstances the Medical
Practitioner will also inform you. Your access to the report will be appropriately limited.
Option C: You may consent to the application for the report but indicate that you do not wish to see
the report before it is supplied. Should you change your mind after the application is made and notify
the medical practitioner in writing they should allow 21 days to elapse after such notification so that
you may arrange to have access to the report (if the report has not already been supplied before you
changed your mind).
Option D: Whether or not you decide to seek access to the report before it is supplied, you have the
right to seek access to it from the medical practitioner at any time up to 6 months after it was supplied.
Information acquired will be included in the student health record in accordance with the Data
Protection Act 1998.
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Appendix 1
Disability disclosure – To be retained by the individual
Section 2c, 2e and 2d of this questionnaire pertain to disability. All information provided will be held
confidentially and treated as medically confidential.
Why is this information being collected?
There are three reasons to collect this information:



Each year all universities have to provide statistics about their staff to the Higher Education
Statistics Agency (HESA). These statistics help to indicate what needs to be done to
encourage more people with disabilities to work in the sector.
To help the university understand how well it is doing in recruiting and supporting disabled
staff. Without an idea of the numbers of disabled staff, it is difficult to know whether our
policies and practices are really providing equal opportunities for disabled people.
The third and most important reason is to provide you with information about the types of
support available to disabled people working at the university.
What does the term disability mean?
The term ‘disabled’ covers a wide range of impairments and health conditions. The definition within
the Equality Act 2010 states ‘a physical or mental impairment which has a substantial and long term
adverse effect on the ability to carry out normal day to day activities.
It would be impossible to provide an exhaustive list but conditions such as arthritis, diabetes,
depression, dyslexia, multiple sclerosis and cancer may be considered a disability
So what now?
If you have a disability you may feel that you have support needs either now or in the future. There is
a range of support available to disabled staff at the university.
Occupational Health department
Staff in the OH department support staff with disabilities. Your support needs can be
discussed with them and advice offered to both you and your manager on making changes;
this may include assistive software, provision in equipment, support workers, modification to
working arrangements. If you would like to speak to a member of the OH team they can be
contacted on telephone number 01482 466011 or by e-mail at occupationalhealth@hull.co.uk
Equality and Diversity Advisor
The Equality and Diversity Advisor can provide advice, information and training on all equality
and diversity issues which includes disability. They can be contacted on 01482 466333 or by
e-mail at a.mwangi@hull.ac.uk
Disabled staff network
The university has a network of disabled staff who provide mutual support and advice to one
another. The network can be accessed by contacting the Equality and Diversity Advisor as
above.
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Appendix 3
Interim Statement: Pre-placement assessment
To:
Recruiting Manager
Human Resources
Name:
Date of Birth:
Location:
Post:
The above named has undergone:
 Health Questionnaire Screening
 Health Assessment
Further action:
 OH are awaiting immunization information
 OH are awaiting medical information.
 Further assessment is required. An appointment has been sent by
Occupational Health the appointment time and date is
 Specialist assessment recommended – OH Department will
Facilitate this
Please Note: The OH pre-placement assessment process has not yet been completed. You will
receive a ‘report of health’ when the process is complete.
Remarks/Recommendations
Signature:
Name:
Designation:
Date:
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Appendix 4
Report of health: Pre- placement Assessment
To:
Recruiting Manager
Human Resources
Name:
Date of Birth:
Location:
Post:
The above named has undergone:
Health Questionnaire Screening
Health Assessment
Outcome
 He/she should be able to offer reliable and effective service for the
above post
 Recommend a workplace assessment to be undertaken by an OH
Team Member on commencement of employment
 Cleared for patient contact
Yes/No/NA
 Cleared for exposure prone procedures (EPP)
Yes/No/N/A
 Cleared to undertake *…………………….as part of their pre-placement
assessment
 Health Surveillance is required. An appointment will be made
to be seen in the OH department
 Recommend a personal emergency evacuation plan (PEEP) is made
Remarks/Recommendations
Signature:
Name:
Designation
Date:
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Appendix 5
Health Questionnaire Paper Screening Check List
Name:
............................................................ Date of Birth: .................................
Job Title: ........................................................ Start Date: .................................
Questionnaire Received Date:
.......................
Health Questionnaire Screened Date:
........................
Further Information Required?
Yes/No
Telephone
Face to Face Appointment
Immunisation Information
Date Interim Report of Health Sent:
Date
Third Party Reports
OHP
........................
Action
Signature
Date Final Report of health sent to H.R./Faculty: .................................
Report Attached:
Yes/No
H.E.S.A. Code:
Yes/No
Code:...........................
Signature: .............................................. Name: ........................................................
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Name
............................................................. Job Title ......................................................
Date of Birth .................................................... Department ..................................................
Date &
Time
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Appendix 6
Process for ‘first pass’ pre-placement assessment by an OH Technician.
Upon receipt of a pre-placement health questionnaire into the OH department the procedure
pertaining to all OH department staff should be followed (section 4.1 and 4.2). An OH Technician
should only undertake ‘first pass’ pre-placement assessment screening once they have been
trained to do so and been signed off as competent.
An Occupational Health Technician can paper screen the health questionnaire which
incorporates the staff disability disclosure questionnaire. The OH Technician should:




Ascertain if there are any fitness for task* (health assessment) issues
Ascertain if any health issues have been declared – section 3
Ascertain if any disability issues have been declared – section 2c,d&e
Ascertain if there are any health surveillance* requirements
If the response to all the above questions is no then the OH Technician can complete an’ OH
Technician report of heath: pre-placement assessment’ (see appendix 7). This should be sent via
e-mail to the recruiting manager and HR assistant, a copy of the report of health and the ‘sent’
e-mail should be printed and filed in the individuals OH record. The OH Technician should then
complete the ‘health questionnaire paper screening check list’ (appendix 5). The relevant section
of the OH database should then be completed. Where required (see section 1b of health
questionnaire) Display screen equipment (DSE) user information should be sent or, the staff
member placed on the pending list for this to be sent at their employment start date. The OH
record can then be filed.
If the individual reports on the questionnaire that they are pregnant or breastfeeding then the
case should be discussed with an OH Nurse and their advice sought before the OH Technician
screening process is completed.
If the response to any of the above questions is yes then the questionnaire should be discussed
with an OH Nurse and their advice sought or returned to the pre-placement folder for screening
by an OH Nurse at a later date. If there is any uncertainty about the responses on the
questionnaire in relation to the above key questions then the questionnaire should be discussed
with an OH Nurse and their advice sought.
*Health assessment/fitness for task includes (this is not an exhaustive list), information in
section 1b is relevant:
Health care workers
Food handlers
Confined space workers
Working at height
Vocational Drivers
Vocational divers
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*Health surveillance includes individuals exposed to health hazards such as (this is not an
exhaustive list) information in section 1b is relevant:
Noise
Hand arm vibration
Respiratory sensitizers including work with animals
Skin sensitizers
Radiation
Asbestos
Lead
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Appendix 7
OH Technician Report of health: Pre- placement
Assessment
To:
Recruiting Manager
Human Resources
Name:
Date of Birth:
Location:
Post:
The above named has undergone:
Health Questionnaire Screening
Outcome
 He/she should be able to offer reliable and effective service for the
above post
Remarks/Recommendations
The above person has not declared any health or disability issues and
they do not require any health surveillance, or any health assessments
in relation to their role
Signature:
Name:
Designation
Date:
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Appendix 8
Occupational Health Department
Occupational Health report with consent – following pre-placement
assessment of clinical practitioners Post Graduate Medical Institute
To: Occupational Health Department
Section 1 Employee details
Name..............................................................................DOB.......................................
The above person has been employed by the University of Hull Post Graduate Medical
Institute.
Section 2 Report
They will be undertaking the role
of....................................................................................................................................
Pre-placement assessment has been undertaken and they have been given health
clearance for the above role.
They are cleared to undertake exposure prone procedures
YES/NO
Section 3 Consent
I (the person named above in section 1) give my consent for the records of my immunisation
history and test results to be copied to the Occupational Health Department at the hospital
where I will be undertaking clinical practice – should they be requested.
Hospital...............................................................Department........................................
Signed................................................................ Date...................................................
Section 4 OH practitioner details
Name of OH practitioner .......................................................... ...................................
Signature.......................................................................................................................
Title .......................................................................................... ..................................
Date...............................................................................................................................
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Appendix 9
Occupational Health Department
T 01482 466010
E occupationalhealth@hull.ac.uk
08 February 2016
Dear
I have been informed that you will shortly be joining the Academic Cardiology department at
the University of Hull to observe clinical practice.
You will therefore need to provide evidence of immunity/immunisation to the following
diseases:
TB
Rubella
Measles
Varicella
Hepatitis B
- evidence of a positive Mantoux/Heaf test or BCG scar
- evidence of immunity
- evidence of immunity
- confirmed history of infection or evidence of vaccination
- evidence of immunisation and of immunity
Should you be involved in surgical procedures we would need to test for Hepatitis C,
Hepatitis B Surface Antigen and HIV.
I enclose a health questionnaire for completion and would be grateful if you could return it to
the Occupational Health Department along with your immunisation details as soon as
possible.
An appointment has been made for you to be seen in the Occupational Health Department
at the University of Hull on
. The Occupational Health Department is situated on
Cottingham Road opposite the main University of Hull campus. The entrance to the
department is at the bottom of the drive to the left of the Newland Health Centre.
Yours sincerely
Name
Title
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Appendix 10
Staff pre-placement assessment guidance
Section 1 -Introduction
This guidance outlines the assessment of physical and mental health issues as part of the staff preplacement health assessment and offers a suggested framework for capturing information. It is
intended for use in face to face assessment, but the framework principles could be applied in a
telephone assessment. It is intended as guidance and to offer a framework to practitioners to
support the assessment process and provide some consistency in assessment within the OH Team. It
is not intended to be prescriptive. This guidance has been adapted from the student pre-registration
health assessment guidance.
During the assessment either the mental health or the physical health assessment may be used
depending on the health issues declared. Equally both may be required.
If during the assessment process it is felt that the individual maybe deemed as disabled under the
terms of the Equality Act 2010, then, consideration should be given to highlighting this to the
recruiting manager/HR and an entry to this effect made in the Occupational Health records.
1. Suggested framework for capturing information – see section 6












Specify whether telephone or face to face assessment
Explore health issues declared – you may wish to use the framework in section 2 and 3
Detail past medical history
Treatment – including medication. This could be current or recent treatment
Investigations - undertaken or awaiting
Social history
Outline of proposed work role – including any fitness for task elements
Occupational History
Consider ability to undertake activities of daily living
Consider any adjustments required
Summary of your opinion
Detail OH actions to be taken
2. Mental health issues
If they declare a mental health issues then the questions in section 2, tier 2 should be asked and
observations made recording responses to questions in the OH records.
Questions
1.
2.
3.
4.
5.
What was it
When was it?
Are you currently suffering from any symptoms?
How was it treated?
Are you currently being treated? If so is it ongoing?
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6. Why did it occur?
7. Are there any effects on activities of daily living?
Observations
Eye contact
Anxiety/agitation
Personal Care
Confidence
Rational thinking
General demeanour
If it is felt that insufficient information is available then the questions at tier 3 should be applied.
Questions
1.
2.
3.
4.
Have you ever had thoughts of harming yourself or others? If so how?
Do you have an eating disorder? If so what type and when?
Is you BMI 16 or below?
Do you have suicidal thoughts? Have you made plans or attempted suicide? If so how and
when?
5. Have you ever been hospitalised due to mental illness? Was this voluntarily or not?
6. Are you/have you received any therapies? If so was this from a counsellor, psychotherapist,
psychologist or psychiatrist? How long and when?
7. Are you/have you received medication? If so what medication/dose, how long for and is this
ongoing?
If it is felt that at stage 3 a clear opinion cannot be formed then tier 4 should be progressed to,
where a number of options are available to the practitioner. They may wish to undertake one or
more options. The options are; discuss the case with the OH team to seek their opinion; discuss the
case with the OHP to seek his opinion; obtain a medical report; refer the student to the OHP for
assessment and opinion.
At any time during stage 2 or 3 the practitioner may wish to progress straight to stage 4, if the
individual is uncooperative or unable to provide the information required the practitioner again may
wish to progress to stage 4.
3. Physical health issues
If they declare a physical health issue then the questions in section 3, tier 2 should be asked and
observations made recording responses to questions in the OH records:
Questions
1.
2.
3.
4.
What was it
When was it?
Are you currently suffering from any symptoms?
How was it treated?
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5. Are you currently being treated? If so is it ongoing?
6. Why did it occur?
7. Are there any effects on activities of daily living?
Observations of




Gait
Use of mobility aids
Hear conversational speech?
Evidence of visual impairment
If it is felt that insufficient information is available then tier 3 should be applied, assessing functional
capability using the assessment tool:
Assessment tool – work ability index see section 5 of guidance
If it is felt that a clear opinion cannot be made then tier 4 should be progressed to, where a number
of options are available to the practitioner. They may wish to undertake one or more options. The
options are; discuss the case with the OH team to seek their opinion; discuss the case with the OHP
to seek his opinion; obtain a medical report; refer the student to the OHP for assessment and
opinion.
At any time during stage 2 or 3 the practitioner may wish to progress straight to stage 4, if the
individual is uncooperative or unable to provide the information required the practitioner again may
wish to progress to stage 4.
Responses to questions and information gathered should be documented in the Occupational Health
records in line with the OH department Local operating procedure for record keeping.
Section 2- Aide memoire – mental health
Tier 1
Individual has declared on their pre-placement questionnaire that they have suffered with a mental
health problems. This should be confirmed with them
If they confirm yes move to tier 2 of the assessment
Tier 2 – Mental health
Observations
Questions
1.
2.
3.
4.
5.
6.
What was it
When was it?
Are you currently suffering from any symptoms?
How was it treated?
Are you currently being treated? If so is it ongoing?
Why did it occur?
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





Eye contact
Anxiety/agitation
Personal Care
Confidence
Rational thinking
General demeanour
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7. Are there any effects on activities of daily living?
If it is felt that further information is required to enable full assessment move to tier 3 of the
assessment
Tier 3-mental health
Questions
1.
2.
3.
4.
Have you ever had thoughts of harming yourself or others? If so how?
Do you have an eating disorder? If so what type and when?
Is you BMI 16 or below?
Do you have suicidal thoughts? Have you made plans or attempted suicide? If so
how and when?
5. Have you ever been hospitalised due to mental illness? Was this voluntarily or not?
6. Are you/have you received any therapies? If so was this from a counsellor,
psychotherapist, psychologist or psychiatrist? How long and when?
7. Are you/have you received medication? If so what medication/dose, how long for
and is this ongoing?
If it is felt that a clear opinion on medical fitness for the proposed role cannot be made or the
reasonable adjustments to support the individual in the role cannot be identified then move to
tier 4 of the assessment
Tier 4 – mental health
One or more of the following options may be taken
 Team discussion – Nurses
 Discussion of case with the OHP
 Obtaining a medical report
 Refer to OHP for assessment
 No further action at present
Section 3 - Aide Memoire Physical health
Tier 1 Physical health
Individual has declared on their pre-placement questionnaire that they have suffered with a physical
health problems. This should be confirmed with them
If they confirm yes move to tier 2 of the assessment
Observations
Tier 2 – physical health
Questions
1. What was it
2. When was it?
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


Gait
Use of mobility aids
Hear conversational
speech?
 Evidence of visual
impairment
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3.
4.
5.
6.
7.
Are you currently suffering from any symptoms?
How was it treated?
Are you currently being treated? If so is it ongoing?
Why did it occur?
Are there any effects on activities of daily living?
If it is felt that further information is required to enable full assessment move to tier 3 of the
assessment
Tier 3-physical health
Assessment tool – work ability index (see appendix 4)
If it is felt that a clear opinion on medical fitness for the proposed role cannot be made or the
reasonable adjustments to support the individual in the role cannot be identified then move to
tier 4 of the assessment
Tier 4 – physical health
One or more of the following options may be taken





Team discussion – Nurses
Discussion of case with the OHP
Obtaining a medical report
Refer to OHP for assessment
No further action at present
Section 4 – Issues for consideration – mental health assessment

Consider nature, duration and severity of condition including level of awareness/ insight into
condition – lack of self awareness increases risks

When was the client last treated?
o Community Mental Health Team
o Therapy
o Where they recently discharged
o Consider what medication past and current
Risks are increased if currently or recently engaged with services


What has the client done in recent years?
o Where they actively engaged in study
o Where they holding down work
o Are there any gaps in activity/periods of inactivity
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

Mental Health robustness is needed to work/study
Look for evidence of productivity in the last year

Patterns of illness
o Recurrent illness or one off episode?
o Circumstances of illness
 Stress
 Drugs
 Transition
o Any evidence of non-compliance
o Lifestyle - ? abusive partner


Insight into illness
o Recognition of patterns
o Efforts to change patterns
o Evidence of insight into vulnerability to relapse
o Do they acknowledge they need support?
o Have they engaged with support services
Look for evidence of insight into condition

Domestic situation
o
o
o
o

What support network do they have (if any)
 Friends
 Family
Any financial pressures
Evidence that they can form appropriate relationships
Family history of mental illness
Triggers
o Are there any identifiable triggers for episodes of mental ill health /relapses
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Section 5– Work ability index
1. Current work ability compared with the lifetime best
Assume that your work ability at its best has a value of 10 points.
How many points would you give your current work ability?
(0 means that you cannot currently work at all)
unable to work at present
0
1
work ability at present
2
3
4
5
6
7
8
9
10
2. Work ability in relation to the demands of the job
How do you rate your current work ability with respect to the physical demands of your
work?
very good
5
rather good 4
amoderate 3
rather poor 2
very poor
1
How do you rate your current work ability with respect to the mental demands of your work?
very good
5
rather good 4
amoderate 3
rather poor 2
very poor
1
3. Number of current diseases diagnosed by a physician
In the following list, mark your diseases or injuries. Also indicate whether a physician has
diagnosed or treated these diseases. For each disease, therefore, there can be 2, 1, or no
alternatives circled.
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Injury from accidents
01 back
02 arm/hand
03 leg/foot
04 other part of body, where
and what kind of injury?
Yes - own opinion
Yes – Physician’s opinion
2
2
2
2
1
1
1
1
2
1
2
1
2
1
2
1
2
2
1
1
2
1
2
1
2
1
2
2
1
1
2
1
2
2
2
1
1
1
...............................................
Musculoskeletal disease
05 disorder of the upper back
or cervical
spine, repeated instances of
pain
06 disorder of the lower back,
repeated instances of pain
07 (sciatica) pain radiating from
the back into the leg
08 Musculoskeletal disorder
affecting the limbs (hands,
feet),
repeated instances of pain
09 rheumatoid arthritis
10 other musculoskeletal
disorder, what?
..............................................
Cardiovascular diseases
11 hypertension (high blood
pressure)
12 Coronary heart disease,
chest pains during exercise
(angina pectoris)
13 coronary thrombosis,
myocardial infarction
14. cardiac insuffi ciency
15 other cardiovascular
disease, what?
................................................
Respiratory disease
16 repeated infections of the
respiratory tract (also tonsillitis,
acute sinusitis,
acute bronchitis)
17 chronic bronchitis
18 chronic sinusitis
19 bronchial asthma
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20 emphysema
21 pulmonary tuberculosis
22 other respiratory disease,
what?
2
2
2
1
1
1
2
1
2
1
2
1
2
1
2
1
2
1
2
2
2
2
1
1
1
1
2
2
1
1
2
2
2
1
1
1
.................................................
Mental disorder
23 mental disease or severe
mental
health problem (for example,
severe
depression, mental
disturbance)
24 slight mental disorder or
problem
(for example, slight depression,
tension, anxiety, insomnia)
Neurological and sensory
disease
25 problems or injury to
hearing
26 visual disease or injury
(other
than refractive error)
27 neurological disease (for
example
stroke, neuralgia, migraine,
epilepsy)
28 other neurological or
sensory
disease, what?
.................................................
Digestive disease
29 gall stones or disease
30 liver or pancreatic disease
31 gastric or duodenal ulcer
32 gastritis or duodenal
irritation
33 colonic irritation, colitis
34 other digestive disease,
what?
Genitourinary disease
35 urinary tract infection
36 kidney disease
37 genitals disease (for
example
fallopian tube infection in
women
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or prostatic infection in men
38 Other genitourinary disease,
what?
Skin diseases
39 allergic rash, eczema
40 other rash, what
41 other skin disease, what?
Tumour
42 benign tumour
43 malignant tumour (cancer),
where?
2
1
2
2
2
1
1
1
2
2
1
1
2
2
2
1
1
1
2
1
2
2
1
1
2
1
2
1
.................................................
Endocrine and metabolic
diseases
44 obesity
45 diabetes
46 goitre or others thyroid
disease
47 other endocrine or
metabolic disease,
what?
.................................................
Blood diseases
48 anaemia
49 other blood disorder, what?
..................................................
Birth defects
50 birth defect, what?
..................................................
Other disorder or disease
51 What?
..................................................
4. Estimated work impairment due to diseases
Is your illness or injury a hindrance to your current job?
Circle more than one alternative if needed.
There is no hindrance/I have no diseases
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I am able to do my job, but it causes some symptoms
5
I must sometimes slow down my work pace or change
4
my work methods
I must often slow down my work pace or change my work methods
3
Because of my disease, I feel I am able to do only part-time work
2
In my opinion, I am entirely unable to work
1
TOTAL SCORE
Evaluation
Completion of the questionnaire results in a figure or score which lies between 7 and 49. The figure
describes the current work ability of the respondents and, at the same time, permits forecasts to be
made of the health risk. A high value indicates a good work ability, a lower value an unsatisfactory or
jeopardised work ability. Depending on the level of the figure it is recommended to maintain,
support, improve or reinstate the work ability
Result
2-27
28-36
37-43
44-49
Category
poor
medium
good
Very good
Work ability action
Reinstate work ability
Improve work ability
Support work ability
Maintain work ability
Note: low work ability values indicate incongruity between the work demands and the work
capability of the employee.
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Section 6 - Suggested framework for capturing information
Telephone or face to face assessment
Include if face to face the location of the assessment, document that you have explained the
purpose of the assessment and that you have discussed confidentiality
Health issues declared
Detail and explore health issues - you may wish to use the framework in appendix 1 and 2
Past medical history
Treatment
Including medication. This could be current or recent treatment
Investigations
Undertaken or awaiting
Social history
Outline of proposed work role
Including any fitness for task elements, shift patterns, hours of work
Occupational History
Activities of daily living
Consider ability to undertake activities of daily living and any limitations
Adjustments
Consider any adjustments required, whether these would be permanent or temporary
Summary of your opinion
Include whether the individual is likely to be deemed as disabled under the Equality Act 2012
Detail OH actions to be taken
Signature, name title
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Occupational Health
Department
Appendix 11
Information for managers – pre-placement assessment
What is a pre-placement assessment?
It is a health and disability assessment undertaken prior to a new employee starting in post or
moving from one post to another. They were previously known as pre-employment assessments.
Why do we do them?
There are three main reasons:



To identify health/disability issues that require support at work, which supports the
requirements of the Equality Act 2010
Assess ‘fitness for task’ where required, for example a health care worker assessment for
staff working in health care
To assess the need for baseline health surveillance where required, for example staff
working with high levels of noise requiring hearing tests.
What does the recruiting manager need to do?
Fully complete page one of the questionnaire. This provides the OH Team with all the information to
make a full assessment and, therefore offer you the most accurate advice. We are unlikely to be able
to complete the assessment without this information.
How long does it take to clear an individual?
Most assessments can be completed within one or two days, however some will take longer. This
may be because an individual needs to be seen by an Occupational Health Nurse/Advisor, a medical
report obtained or a referral to the Occupational Health Physician. We will keep you updated at each
stage, when we have screened a pre-placement assessment but cannot offer a health opinion we
will send you an interim statement outlining our next steps. The OH department has a KPI for preplacement assessment. We endeavour to complete the assessment as quickly as possible.
How will I know when an individual is health cleared?
You will receive via E-mail a ‘Report of Health’ from OH. This will provide our health opinion and any
recommendations.
What do I do if I have any questions or concerns?
At any stage you may contact the OH Department to discuss any concerns or raise any questions you
have. Telephone 466011, E-mail occupationalhealth@hull.ac.uk
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