Occupational Health Form

All information provided by you in this questionnaire or later discussed in a consultation with an OH Advisor/ Clinician or OH Physician will be treated in complete confidentiality and will form part of your confidential OH medical record.

The information given on this form and any subsequent medical examinations will be used to form an opinion on whether you are medically fit for a certain role and whether you can carry out a role without a significant risk to your own or others’ health and safety. The information can also be used to decide whether any adjustments will be needed in a place of work.

Step 1 of 8

Company details
Company name*
Job title*
Your details
Name*
Forename(s) Surname
Date of birth*
DD slash MM slash YYYY
Gender*
- Male
- Female
- Other
Full Postal Address*
Street Address Address Line 2 City ZIP / Postal Code Country
London address
Street Address Address Line 2 City ZIP / Postal Code Country
General Practitioner’s Details
GP’s Name*
Telephone Number*
Surgery Name & full postal address*
Name Street Address City ZIP / Postal Code Country
Please answer ALL the following questions. . The Equality Act 2010 defines a person with a disability as “A physical or mental impairment, which has a substantial adverse long term effect on his or her ability to carry out normal day to day activities.”
Do you have a disability which may affect your ability to undertake the proposed role or which requires special arrangements?*
- Yes
- No
If yes, what facilities/adjustments/equipment might enable you to perform the role?

ACCESS TO MEDICAL REPORTS ACT 1988 (Revised September 1995)
Summary of Rights Related to Medical Reports Obtained from GP’s and Medical Consultants

No application may be made to a General Practitioner or Consultant for a medical report relating to an employee without:

a) the employee being notified that a report is being requested, and
b) the employee’s consent to the application being made

An employee has the right to:
- refuse to allow a report to be requested from a General Practitioner or Specialist
- request to see the report before it is sent
- refuse to allow the report to be sent, after having seen it
- request that changes to be made to the report before it is sent because he/she considers it to be incorrect or misleading, (this request must be made to the GP in writing) or
- request that his/her views are attached to the report if there is any part of it with which he/she disagrees and which the GP or specialist is not prepared to alter, (again this request must be made to the GP in writing).
If the employee requests access to the report before it is supplied, The London General Practice must:
- notify the employee when the report is being requested from the GP or specialist
- notify the GP or specialist that the employee has made such a request
The GP or specialist may not then supply the report unless:
a) consent has been given;
or
b) the report has been amended to take account of the employee’s views or a statement of
those views has been attached to it;
or
c) a period of 21 days from the date the application for the report was made has gone by without the employee having contacted the GP to make arrangements to see the report.

If an employee consents to the report being obtained without requiring access to it prior to it being given to The London General Practice, but subsequently decides that he/she wishes to have access to it, he/she may approach the GP or specialist direct. In such circumstances the GP or specialist may not give the report to The London General Practice without the employee’s consent (subject to any amendments), or until a period of 21 days has passed since the employee indicated his/her wish to see the report, without the employee having contacted the GP to make arrangements to see the report.

A GP or specialist is required to give an employee access to any medical report supplied about him/her for employment or insurance purposes in the previous six months, at the employee’s request.

A GP or specialist is not obliged to give access to a medical report where disclosure would, in the opinion of the GP or specialist, cause serious harm to the physical or mental health of the employee, or others, or would indicate the intentions of the GP or specialist in respect of the employee or where disclosure would reveal information about another person who has supplied information to the GP or specialist, unless that person has consented, or is a health professional where the information was provided in a professional capacity.

In these circumstances the GP or specialist will inform the employee that this is so, and will give access to any parts of the report not affected by the above clauses. The GP or specialist
will not pass on the report unless the employee gives consent.
Independent Medical Reports – Medical Reports prepared by The London General Practice doctors and sent to your employer
The Access to Medical Reports Act 1988 applies only to medical reports written by a medical practitioner who has been involved in some way in the diagnosis or treatment of the individual patient. Thus, medical reports written by “experts” or indeed by any doctor who has never been involved in treating the patient are excluded from this legislation.

However, it is The London General Practice’s policy that its doctors should be prepared to discuss with the employee the purpose of the assessment, content of their reports and especially the type of questions that they are being asked to answer. It is also our policy to
send a copy of the completed occupational health report to the employee should they wish to receive one.

Should you wish to make any comment about the occupational health report please contact your Human Resources Department who will liaise with The London General Practice on your behalf.

CONSENT FORM TO RELEASE OCCUPATIONAL HEALTH REPORT
Please Only Tick One Box*
- 1) I give consent for the occupational health report to be released without prior viewing. I do not require a copy to be sent to my home address.
- 2) I give consent for the occupational health report to be released without prior viewing. I would like a copy to be sent to my home address.
- 3) I would like to view the occupational health report before it is released to my employer. I am aware that if I choose to respond to the contents of the report, I have up to 48 hours upon receipt by email to do so. I have up to 5 working days to respond and for it to be returned if the report is posted to me. If no response is received within the stipulated timescales, I am aware that the report will be released. I am also aware that the doctor can only amend factual inaccuracies and not opinions. If the doctor is unable to amend the report, I consent for the report to be released to my employer with my comments attached to it.
- 4) I do not consent for the occupational health report to be released.
Please Only Tick One Box
- Send Report By Email To (Provide Email Address):
- Send Report By Post To (Provide Mailing Address):
Email Address
Enter Email Confirm Email
Mailing Address*
Street Address Address Line 2 City ZIP / Postal Code Country
Name*
Date*
DD slash MM slash YYYY
Signed

AUTHORISATION FOR THE RELEASE OF MEDICAL INFORMATION
Name*
Forenames Surname
Date of Birth*
DD slash MM slash YYYY
Home Address*
Street Address Address Line 2 City ZIP / Postal Code Country
Telephone No*
Name of Medical practitioner*
Forenames Surname
Address*
Street Address Address Line 2 City ZIP / Postal Code Country
Telephone No*
Name of Hospital Specialist (if appropriate)
Forenames Surname
Address
Street Address Address Line 2 City ZIP / Postal Code Country
Telephone No
Signature of Authorisation
- I consent to a medical report from my doctor/specialist being supplied to The London General Practice.
- I consent to medical reports from my doctor/specialist being supplied to my employer.
Employee’s signature
Today’s Date*
DD slash MM slash YYYY

Occupational Health Form

Step 1 of 8

Company details

Your details

General Practitioner’s Details

Medical Conditions

Sickness Absence

Family History

Past Medical History

Smoking

Alcohol History

Immunisation Status

Declaration

ACCESS TO MEDICAL REPORTS ACT 1988 (Revised September 1995)

Independent Medical Reports – Medical Reports prepared by The London General Practice doctors and sent to your employer

CONSENT FORM TO RELEASE OCCUPATIONAL HEALTH REPORT

AUTHORISATION FOR THE RELEASE OF MEDICAL INFORMATION