Medmark4teachers :: Pre-employment Questionnaire For Teachers

Pre-employment Questionnaire For Teachers

Introduction: The purpose of the pre-employment medical questionnaire is to enable Medmark: determine the fitness of applicants to safely carry out duties of the intended position whilst ensuring compliance with Employment Equality legislation. screen for underlying medical disorders so that the employers can meet their responsibilities under Health and Safety & Disability Legislation 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. 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 Personal Public Service Number (PPSN) 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 if 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
PPSN	School Roll Number		Date of birth
Home Address	Name and Address of School		Contact phone numbers (landline & mobile) & e-mail address Landline: Mobile: Email:
Type of School, tick as appropriate Primary Secondary VEC	If you teach any of the following subject, tick as appropriate 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.
	Yes	No	Details
Have you ever completed a pre-employment medical questionnaire for Medmark? If so, please give details
Have you ever been treated or had counselling for any addiction disorder, alcohol or drug abuse? If so, please give details.
Do you smoke? If yes, please quantify your daily intake
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
Have you ever been denied a job on health grounds?
Have you ever been medically retired from any job, or left any job because of ill health? Please give details.
Have you ever had any illness or health related problem that may have been caused or made worse by your work?
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.
Are you currently taking any medication? If yes, please state why and the name of the medication.
Are you currently receiving or waiting for, any medication, treatment or investigation at the moment? If so, please give details.
Have you ever had any illness, medical problem or disability that may currently affect your ability to work safely as a teacher
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	Yes	No	Details
Lung/Chest Problems? e.g. Asthma, TB, Pneumonia, Bronchitis
Heart problems or circulatory disorders? e.g. Heart Murmur, Heart Attack, High Blood Pressure, Anaemia, Circulatory Problems, e.g. varicose veins/ankle swelling.
Stomach, Bowel or liver disease, gallbladder or pancreatic problems.
Prostate problems, bladder or continence problems, kidney disorders? e.g. Kidney stones, infections, kidney failure.
Glandular problems? e.g., diabetes or thyroid problems.
Disorders of the nervous system? e.g. fits, blackouts, migraine, recurring headaches, epilepsy, stroke, mini stroke, dementia
Psychiatric or mental health illness or psychological problems including anxiety, depression, schizophrenia, nervous breakdown, eating disorders (anorexia/bulimia), panic attacks, burnout
Fatigue syndrome? e .g. post viral fatigue, M.E.
Do you have any eye disorder not corrected with glasses or any other eye problems e.g. colour blindness, lazy eye, glaucoma, cataracts etc.,
Ears, nose, throat or any voice disorders? e.g. deafness, tinnitus, voice weakness/voice projection difficulties, recurring laryngitis
Skin problems? e.g eczema, dermatitis, psoriasis.
Tumours – benign or malignant?
Allergies? e.g. to drugs, food, chemicals.
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
Work related upper limb disorder (WRULD) or repetitive strain injury (RSI), tendonitis?
Any gynaecological problems?
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 That my employer will have reasonable expectation that I will provide regular attendance at school 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 to teach to the named school. I agree with the above declaration.