Hearing Questionnaire

Enniscorthy Medical Centre
www.enniscorthymedicalcentre.com
Email: info@enniscorthymedicalcentre.com

Tel: 053 92 395 12
Fax: 053 92 434 59

The purpose of this questionnaire is to assist Enniscorthy Medical Centre in determining your fitness to carry out your duties safely in your current or proposed workplace in compliance with employment law.

  • Screening for medical problems such as hearing loss will also assist your employer in meeting his/her obligations under Health & Safety law.
  • This questionnaire will form part of your occupational health record which will be held by Enniscorthy Medical Centre.
  • This questionnaire may be stored in paper or electronic form in compliance with data protection law for possible future reference.

Instructions:

Please answer all sections and questions as completely as possible. If additional information is required or if clarification is required, an occupational health nurse or doctor may contact you.

If you indicate yes to any of the questions listed please name the illness, date when symptoms started and when the diagnosis was made. State if you attended a doctor, specialist or health facility and if investigations were carried out and the results of such investigations.

Please give details of any treatment you may have had such as surgery/medication and state if you are currently taking medication and/or having treatment such as physiotherapy etc.

  • If you required time off work please indicate when this was and for how long.
  • If you have not fully recovered from your illness please state how this affects you.
  • If you believe your illness is work related please give details.
Hearing

Maximum file size: 8MB

Former Occupation(s)
Please provide some detail concerning previous jobs in which you have worked.
Please answer yes or no to the following questions. If yes please give details.
Please list the work areas that you consider noisy in your present job.
Declaration:
I understand that the purpose of this hearing questionnaire is to confirm that

  1. I am fit for the position I have applied for or currently working.
  2. I can perform my duties safely and without risk to the health and safety of others.
  3. I can render reliable and productive service for my employer

I declare that the information I have given is true and accurate to the best of my knowledge and that I have not withheld any material facts. I understand that I am responsible for the accuracy or otherwise of the answers above. I understand that if I have knowingly withheld material facts this may affect my appointment or continued employment.