Gipping Skin Surveillance Record Questionnaire

Personal Details

Name

Prefix First Names Surname

Home Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email Address

Home Phone Number

Work Phone Number

Mobile Phone Number

Date of Birth

Doctor's Name

Doctor's Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Doctor's Contact Number

Employer

Role

Employment Address

Street Address City County / State / Region ZIP / Postal Code Country

Manager's Name

Do you have any current skin problems?

Please provide details

What skin hazards are you / have you been exposed to? (e.g. chemicals, oils)

What personal protective equipment do you wear / have you worn?

Length of time in current job role?

Length of time with current company?

Any previous skin problems?

Please provide details

The Health and Safety at Work Act 1974, requires employers to ensure, so far as is reasonably practicable, your health, safety and welfare while at work. To help us to help you and your employer, we are asking you to complete this form before attending for your health assessment and Skin Surveillance appointment. This will form part of your confidential Occupational Health Records. At the health assessment, you will be asked further questions about your health and your work. Medical information is held in Confidence by the Occupational Health Service and is not passed on without your specific written consent. The use of personal sensitive information is regulated in law by the General Data Protection Regulations (GDPR) and covered by the ethical requirements of the General Medical Council/Nursing & Midwifery Council. A copy of our Privacy Notice which relates to how we handle your personal sensitive information is available on request.
Any information requested from a treating Doctor is in accordance with the Access to Medical Reports Act 1988 and the General Data Protection Regulations.
Any information supplied to your employer is about your ability to work safely and without detriment to your health. You may withdraw your consent to release personal sensitive information to your employer at any point.

Declaration

I declare that each and every answer above is true to the best of my knowledge and belief.