Stranmillis University College - Occupational Health Service - Confidential Health Declaration 2020-21

CONFIDENTIAL HEALTH DECLARATION

Data Protection Information

If you become a student at Stranmillis University College (SUC) this Declaration of Health will form the basis of your Occupational Health (OH) record. In compliance with the General Data Protection Regulation 2016/679 information will be held securely in confidence by the Occupational Health Provider (independent Occupational Health), which may include computer storage.

The answers provided on this questionnaire will be confidential to Occupational Health and will not be disclosed to anyone without your consent.

Please complete and submit this form AS SOON AS POSSIBLE and no later than the commencement date of your degree course.

1. Your Details *

Surname	*
Forename(s)	*
Email Address	*
Home Phone Number	*
Mobile Phone Number	*
UCAS ID (If not known, enter None)	*

2. What is your Date of Birth *

	DD/MM/YYYY

3. Your full home address: *

Address Line 1	*
Address Line 2 (if required)
City/Town	*
Postcode	*

4. Next of Kin: *

Name of next of kin	*
Address Line 1	*
Address Line 2 (if required)
City/Town	*
Postcode	*
Phone number	*

5. General Practitioner Name and Address: *

GP Name	*
Address Line 1	*
Address Line 2 (if required)
City/Town	*
Postcode	*
Phone number	*

6. FIRM CHOICE

If you are holding a firm choice at Stranmillis University College, please select the course below.

7. INSURANCE CHOICE

If you are holding an insurance choice at Stranmillis University College, please select the course below.

8. PREVIOUS SICKNESS ABSENCE

Have you had any illness/injury which has kept you from your usual activities in school, work, or leisure, for more than five days in the last two years? *

Yes
No

If Yes, please state: 1)Year 2)Length of Absence 3)Reason for Absence

HEALTH DECLARATION

Responses to the following questions will be used to confirm your fitness to undertake a course of study at Stranmillis University College (SUC) and if required, will help us to determine the support and/or adjustments you may require.

9. Current Health

Are you currently having any sort of treatment? E.g. physiotherapy, chiropractic, counselling, cognitive behaviour therapy (CBT) etc. *

Yes
No

If 'Yes', please give further information.

10. Current Health

Are you waiting for any medical treatment, tests or investigations for an existing symptoms/condition? *

Yes
No

If 'Yes', please give further information.

11. Current Health

Have you full awareness of your own mental health, when to seek help and from whom? *

Yes
No

If 'Yes', please give further information.

FUNCTIONAL CAPACITY

The following set of questions relate to Functional Capacity

12. Functional Capacity

Do you suffer from or have you been treated for any of the following within the last 5 years?

Musculo-skeletal problems e.g. arthritis and/or pains in the joints, hands, legs, neck or back? *

Yes
No

If 'Yes', please give further information.

13. Functional Capacity

Do you suffer from or have you been treated for any of the following within the last 5 years?

Mobility problems e.g. walking, using stairs, balance? *

Yes
No

If 'Yes', please give further information.

14. Functional Capacity

Do you suffer from or have you been treated for any of the following within the last 5 years?

Agility problems e.g. bending, reaching up, kneeling down? *

Yes
No

If 'Yes', please give further information.

15. Functional Capacity

Do you suffer from or have you been treated for any of the following within the last 5 years?

Dexterity problems e.g. getting dressed, writing, using tools? *

Yes
No

If 'Yes', please give further information.

16. Functional Capacity

Do you suffer from or have you been treated for any of the following within the last 5 years?

Communication problems e.g. speech, hearing & vision? Hearing conditions such as tinnitus, hearing loss, ear surgery (other than grommets) *

Yes
No

If 'Yes', please give further information.

17. Functional Capacity

Do you suffer from or have you been treated for any of the following within the last 5 years?

Visual disorder not corrected by the wearing of lenses or spectacles e.g. double vision or loss of vision *

Yes
No

If 'Yes', please give further information.

18. Functional Capacity

Do you suffer from or have you been treated for any of the following within the last 5 years?

Infections e.g. tuberculosis, HIV, hepatitis, skin condition *

Yes
No

If 'Yes', please give further information.

19. Functional Capacity

Do you suffer from or have you been treated for any of the following within the last 5 years?

Neurological conditions e.g. epilepsy, seizures, sudden loss of consciousness e.g. recurrent faints/blackouts, headaches, migraine, multiple sclerosis *

Yes
No

If 'Yes', please give further information.

20. Functional Capacity

Do you suffer from or have you been treated for any of the following within the last 5 years?

Mental illness, emotional or psychological conditions e.g. stress, depression, anxiety, panic attacks, phobias, bi-polar disorders, overdose or self-harm, obsessive compulsive disorder, chronic fatigue *

Yes
No

If 'Yes', please give further information.

OTHER HEALTH CONDITIONS

The following set of questions relate to Other Health Conditions

21. Other Health Conditions

Do you suffer from or have you been treated for any of the following within the last 5 years?

Eating disorders e.g. bulimia, anorexia nervosa, compulsive eating? *

Yes
No

If 'Yes', please give further information.

22. Other Health Conditions

Do you suffer from or have you been treated for any of the following within the last 5 years?

Abuse and/or Misuse of illegal/recreational drugs and/or alcohol *

Yes
No

If 'Yes', please give further information.

23. Other Health Conditions

Do you suffer from or have you been treated for any of the following within the last 5 years?

Cardiovascular conditions e.g. transient ischaemic attacks, stroke, angina, heart disease or heart surgery *

Yes
No

If 'Yes', please give further information.

24. Other Health Conditions

Do you suffer from or have you been treated for any of the following within the last 5 years?

Respiratory/breathing problems e.g. asthma, bronchitis, COPD, tuberculosis *

Yes
No

If 'Yes', please give further information.

25. Other Health Conditions

Do you suffer from or have you been treated for any of the following within the last 5 years?

Diabetes *

Yes
No

If 'Yes', please give further information.

26. Other Health Conditions

Do you suffer from or have you been treated for any of the following within the last 5 years?

Gastric problems e.g. ulcerative colitis, Crohn’s disease, irritable bowel *

Yes
No

If 'Yes', please give further information.

27. Other Health Conditions

Do you suffer from or have you been treated for any of the following within the last 5 years?

Cancer or immune-suppression due to an illness or treatment? *

Yes
No

If 'Yes', please give further information.

ADDITIONAL SUPPORT

The following set of questions relate to Additional Support

28. Additional Support

Do you have a health condition that you believe would be defined as a disability under the Disability Act 1995 (Northern Ireland), i.e. affects your ability to carry out normal day to day activities for at least twelve months or likely to last longer than twelve months or HIV, cancer or multiple sclerosis? *

Yes
No

If 'Yes', please give further information.

29. Additional Support

Do you have a health condition that may affect your ability to undertake the proposed teacher training course? *

Yes
No

If 'Yes', please give further information.

30. Additional Support

Do you think any equipment, assistance or adjustments may be required to enable you to undertake any aspect of the proposed course? *

Yes
No

If 'Yes', please give further information.

31. Have you attached GP/Specialists reports if required?

If you have any chronic conditions e.g. diabetes, epilepsy, asthma, mental ill health, neurological conditions please include an up to date report from your GP/Consultant.

Failure to do so, is likely to result in delays in advising on your fitness for the teacher training course

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32. The General Data Protection Regulation 2016/679

Personal information generated by completion of this form will help to provide a medical view of your fitness to complete your degree course. Without this information your application/assessment of fitness will not proceed further. The Occupational Health Adviser or Occupational Health Physician may require further information on your health before coming to a view on your fitness. Your consent to further reports from your medical advisers will be sought in these circumstances before a certificate of fitness/ restrictions /adjustments can be issued. All such medical information will be kept in strict medical confidence by the Occupational Health staff. Your consent will be sought for any other use of all or part of this confidential medical data.

PLEASE READ CAREFULLY BEFORE COMPLETING

I understand that:-

I may be required to attend Stranmillis University College Occupational Health Department for an assessment;

Failure to disclose information or giving false information may result in disciplinary action and may lead to termination of my degree course; and

I must advise the Occupational Health Department of Stranmillis University College if my health deteriorates during my degree course.

I understand that by submitting this form I am declaring that the answers and information included in this Declaration of Health are correct to the best of my knowledge. *

Yes
No

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