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Pre-employment Questionnaire For Teachers & Special Needs Assistants (SNAs)

Introduction: The purpose of the pre-employment medical questionnaire is to enable Medmark to:
  1. determine the fitness of applicants to safely carry out duties of the intended position whilst ensuring compliance with Employment Equality legislation.
  2. screen for underlying medical disorders so that the employers can meet their responsibilities under Health and Safety & Disability Legislation
  3. form the basis of an occupational health record to be held by Medmark. This record may be referred to if the applicant is referred to Medmark at a future date.
Data Protection
The information on this document may be stored in either paper or electronic form. It is for the use of the occupational health service for teachers & Special Needs Assistants. The data will be held in accordance with Data Protection Legislation. The medical information stored will be treated as strictly confidential at all times by Medmark and will not be disclosed to any third parties on an identifiable basis. Statistical information may be compiled on an anonymous basis in group format.

When completing the questionnaire please follow the instructions below.

Complete all sections and answer all questions.

You must provide both your contact details and your school roll number in order for Medmark to consider your application and forward a result to your prospective employer.

If you answer 'YES' to any of the questions under the heading 'HAVE YOU EVER HAD OR DO YOU NOW SUFFER FROM', then provide the following information on the PEMQ1
  • the name the illness
  • state when symptoms first started and when the illness was diagnosed
  • if you attended a specialist /health care professional, give details of who you attended and if investigations/tests were carried out, give details of the results of these investigations/tests. Please state when you last visited a specialist /health care professional and if you have any further appointments
  • if treatment was prescribed, please give details
  • Please indicate if you have completed your treatment and if not indicate when your treatment finishes
  • If you have missed any time from work/college as a consequence of this illness, please give details of when this was and details of the duration of time missed
  • If you have not made a full recovery from this illness, give details of how the illness continues to affect you
  • If you consider your illness is in any way work related, please give details
You may be contacted by the Occupational Health Physician if you do not complete the questionnaire in sufficient detail, and if more information is required. This may delay your application. You may also be requested to attend Medmark for a pre-employment assessment in person.

Thank you for giving this questionnaire your time and attention.

Surname

First Name

Type of Employment

School Roll Number

Date of birth

 

Home Address:




Name and Address of School:




Teacher/SNA Contact phone numbers
(landline & mobile) & e-mail address


Landline:

Mobile:   

Email:    

Type of School, select as appropriate

If you teach of any of the following subjects, tick as appropriate.
If you are an SNA please tick 'none of the above'.

Metal/Woodwork              

Home Economics              

Science                             

Physical Education           

None of the above           

Select Your Security quesion (*remember this as reference for further enquiry)

Your Answer for Security Question (*remember this as reference for further enquiry)

 

PLEASE COMPLETE THE FOLLOWING HEALTH QUESTIONNAIRE:  WHERE A “YES” IS PROVIDED IN ANSWER TO ANY OF THE FOLLOWING QUESTIONS PLEASE PROVIDE SOME DETAILS. 

NOTE: MEDMARK MAY CONTACT YOU FOR CLARIFICATION WHERE MEDICAL INFORMATION IS INCOMPLETE.

 

Details

1. Have you ever completed a pre-employment medical questionnaire for Medmark? If so, please give details

2. Have you ever been treated or had counselling for any addiction disorder, alcohol or drug abuse?  If so, please give details.

3. Do you smoke?
If yes, please quantify your daily intake

4. Do you drink alcohol?If  yes, what is your weekly consumption of alcohol in units?  1 Pint Beer   =  2 Units          Spirit  =  1 ½ Units Glass Wine   =  1 Unit

5. Have you ever been denied a job on health grounds?

6. Have you ever been medically retired from any job, or left any job because of ill health? Please give details.

7. Have you ever had any illness or health related problem that may have been caused or made worse by your work?

8. Have you attended any doctor for medical care or treatment in the last five years for any kind of health problem? If so, please give reasons.

9. Are you currently taking any medication? If yes, please state why and the name of the medication.

10. Are you currently receiving or waiting for, any medication, treatment or investigation at the moment?  If so, please give details.

11. Have you ever had any illness, medical problem or disability that may currently affect your ability to work safely as a teacher or SNA

12. Have you had any days off sick in the last 2 years? If yes, please give number of days and reasons to the best of your recollection.

 

PLEASE COMPLETE THE FOLLOWING HEALTH QUESTIONNAIRE:  WHERE A “YES” IS PROVIDED IN ANSWER TO ANY OF THE FOLLOWING QUESTIONS PLEASE PROVIDE SOME DETAILS TO INLUDE RELEVANT DATES, DIAGNOSIS, TREATMENT, ONGOING SYMPTOMS. 

NOTE: MEDMARK MAY CONTACT YOU FOR CLARIFICATION WHERE MEDICAL INFORMATION IS INCOMPLETE.

HAVE YOU EVER HAD OR DO YOU NOW SUFFER FROM

Details

13. Lung/Chest Problems? e.g. Asthma, TB, Pneumonia, Bronchitis

14. Heart problems or circulatory disorders? e.g. Heart Murmur, Heart Attack, High Blood Pressure, Anaemia, Circulatory Problems, e.g. varicose veins/ankle swelling.

15. Stomach, Bowel or liver disease, gallbladder or pancreatic problems.

16. Prostate problems, bladder or continence problems, kidney disorders? e.g. Kidney stones, infections, kidney failure.

17. Glandular problems? e.g., diabetes or thyroid problems.

 

18. Disorders of the nervous system? e.g. fits, blackouts, migraine, recurring headaches, epilepsy, stroke, mini stroke, dementia

19. Psychiatric or mental health illness or psychological problems including anxiety, depression, schizophrenia, nervous breakdown, eating disorders (anorexia/bulimia), panic attacks, burnout

20. Fatigue syndrome? e .g. post viral fatigue, M.E.

21. Do you have any eye disorder not corrected with glasses or any other eye problems e.g. colour blindness, lazy eye, glaucoma, cataracts etc.,

22. Ears, nose, throat or any voice disorders? e.g. deafness, tinnitus, voice weakness/voice projection difficulties, recurring laryngitis

23. Skin problems? e.g eczema, dermatitis, psoriasis.

24. Tumours – benign or malignant?

25. Allergies? e.g. to drugs, food, chemicals.

26. Back, neck, joint problem or arthritis, gout or any other rheumatic disorder?  e.g. backache, disc prolapse, disc/back surgery, soft tissue injury, occupational back injury, arthritis, rheumatism, fibromyalgia

27. Work related upper limb disorder (WRULD) or repetitive strain injury (RSI), tendonitis?

28. Any gynaecological problems?

29. Any other accidents, illness or injuries?

OCCUPATIONAL HISTORY

Please provide some detail concerning recent positions you have held

Workplace

From Date

To Date

Job Description


DECLARATION

I understand that the purpose of this Pre-Employment Medical Questionnaire is to establish the following:

  • That I am fit for the post for which I am making application
  • That I can carry out the duties of the post without any undue risk to the health and safety of myself or any other person

I declare that the information I have given is true and complete to the best of my knowledge and that I have not withheld any material facts. I understand that I am responsible for the accuracy of my statement and that if I wilfully suppress and information I risk the loss of appointment. I understand that by submitting this pre employment questionnaire I consent to Medmark Occupational Health furnishing notification concerning my fitness for work with the named school.

I agree with the above declaration.

 
 
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