Ionising Radiation – Review

To submit your answers to the Ionising Radiation Questionnaire, please complete the online form by answering each of the following questions. All fields marked * are required fields and must be completed. On submission a PDF summary of your completed form shall be emailed to GO Health Services and a copy sent to your own email address.

This questionnaire will be held in confidence by GO Health Services and will form part of your Occupational Health record. For full details of how your personal information is used please see our GDPR Statement.

This form is also available in other formats and languages, upon request. Please Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245 for further information.

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SECTION 1: PERSONAL DETAILS

Forename *

Surname *

Date of Birth *

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Address *

Telephone Number *

Work Email Address *

Email

Confirm Email

Job Title/Role *

Employer/Department *

Manager's Name *

Manager's Email Address *

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SECTION 2: Please complete the following questions

Please provide further details on any ‘Yes’ answer.

Date of your last face to face ionising radiation medical examination: *

Any changes to your duties since the last ionising radiation medical examination/review? * YesNo

If Yes please provide more information:

Have you had any sickness absences since your last ionising radiation medical examination/review? * YesNo

If Yes please provide more information:

Any changes to your health since the last ionising radiation medical examination/review? * YesNo

If Yes please provide more information:

Have you been prescribed any new medications in the last 12 months? * YesNo

If Yes please provide reason(s) for and further details:

Are you or could you be pregnant or breastfeeding? * YesNo

If Yes please provide more information: *

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