Lincolnshire County Council (LCC) welcomes and values the partnership which has evolved between the Council and the many volunteers who commit their time and enthusiasm to supporting a whole range of important services. The council recognises that many have given years of voluntary service and bring experience and expertise which might be very difficult or impossible to replace.
LCC is in a special position as a public body and therefore has a number of obligations. One of these is to exercise a proper concern for the welfare and safety not only of its employees but of volunteers and members of the public who serve within or come into contact with the Council’s services. All prospective employees of the Council have to complete a very comprehensive form relating to their medical fitness for employment and although volunteers are not paid employees the same duty of care must apply.
Some of the questions asked in this form are of a very personal nature and may seem intrusive. We have, however, attempted to keep this intrusion to a minimum. All information supplied will, of course, be treated in the strictest confidence and the Council will certainly do all possible to ensure that no additional obstruction is placed in the way of those who wish, in any capacity, to give freely of their time in support of the Council’s services. We will not discriminate against people in respect to any disability they may have, in line with the Disability Discrimination Act 1995.
The following questionnaire is split into 3 sections: Section 1 should be completed by the volunteer supervisor once an appropriate activity has been identified. Section 2 should be completed by the volunteer. Section 3 should be completed by the occupational health staff.
The completed form should be sent to WellWork Ltd in a sealed envelope by the volunteer. Information declared on this form will be kept by WellWork Ltd as a personal confidential record and in accordance with the Data Protection Act 1998, with a statement of fitness sent to the volunteer’s supervisor.
Section1
(To be completed by the VOLUNTEER SUPERVISOR)
Name of volunteer
Activity
Activity base
Activity frequency (e.g. 3hrs per week)
Starting date
Activity Details
Physical demands:
Work environment – Exposure to:
o Sedentary
o Home working
o Physically active
o Chemicals
o Moving or handling tasks
o Dusts
o Climbing
o Vibration
o Working at heights
o Fumes
o Display screen work
o Noise
o Repetitive upper limb movements
o Radiation
o Confined spaces
Driving:
o Hot temperatures
o Essential car user
o Cold temperatures
o Casual car user
o Blood, body fluids
o PCV/LGV driver
o Infective materials
o Fork lift truck driver
o Animals or animal products
o Full time driver
Special requirements of activity:
o Good hearing
o Food handling
o Good colour vision
o Engaging with persons with challenging behaviour
o Drug and/or alcohol screening
Volunteer Supervisor Details
Print name
Position
Address
Telephone
Email
Signed
Section 2
(To be completed by the VOLUNTEER)
If you have completed this questionnaire in the last six months and your health status has not changed you do not need to complete Q1-Q48 of this form. You do, however, need to confirm your agreement with the statement ‘My health has not altered since completing a previous form’ by signing and providing the date of your previous questionnaire below.
Then please complete the sections headed ‘Fitness for Volunteering’ and ‘Declaration’.
Previous questionnaire completed on (date)
Signature
The purpose of these questions is to ask for sensitive personal data relevant to the safety and performance in your proposed role, assessment of any potential disabilities, and to recommend reasonable adjustments necessary.
Medical information declared on this form will be held in confidence by WellWork Ltd in a separate occupational health file.
Your Previous Health History
1. Heart disease of any kind
Yes o
No o
17. Concussion or head injury
2. High blood pressure
18. Anxiety, depression or psychosis
3. Anaemia or blood condition
19. Other psychological or psychiatric problems
4. Phlebitis or varicose veins
20. Stress at home or work
5. Stroke or mini-stroke
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