proximity to patients or will you handle samples and specimens in the course of your proposed work?                       No ☐           Yes   X   Ensure Immunisation Questionnaire is completed                               |

The purpose of this assessment is to enable Plymouth Hospitals NHS Trust to:

  * Identify any health problems or disabilities that may make the proposed job difficult or unsafe for you or others;
  * Assess what adjustments to the job may be needed to enable you to work if you have a health problem or disability;
  * Protect, maintain and improve your health and well-being.

Please read the list below carefully and place a cross in the ‘Yes’ or ‘No’ box.   If you tick YES, a ‘Full Health Questionnaire’ will need to be completed

  1. Do you have any condition or disability that could affect your ability to undertake any of the requirements detailed within the Job description and Person specification for the role of the proposed post, including hours and shift patterns, without adjustments?
  2. Has your work (hours of work, role or responsibilities) been modified or have you had to leave a job because of a health problem?
  3. Have you had more than 10 days sick in the past 2 years?
  4. Have you been sick on more than 5 separate occasions in any 12 month period in the past 2 years?
  5. Have you ever been affected by insulin dependent diabetes?
  6. Have you ever been affected by epilepsy?
  7. Have you ever been affected by any musculo-skeletal/back pain leading to more than two weeks absence or requiring treatment other than simple over the counter pain killers?
  8. Have you ever been affected by any skin disorders e.g. hand eczema, latex allergy, colonisation or infection with MRSA?
  9. Have you ever been affected by any psychiatric problems e.g. depression, anxiety, stress or substance and/or alcohol misuse?
  10. Have you ever been affected by any communicable disease such as...