Employee Health Survey

Survey Date: January 1, 2050

Employee Name (optional): [Your Name]

HEALTH ASSESSMENT

1. Have you experienced any recent health issues or symptoms that may affect your ability to work safely?

• Yes

• No

• Prefer not to answer

2. Are you currently taking any medication or undergoing any medical treatment that may impact your work performance or safety?

• Yes

• No

• Prefer not to answer

3. Have you been in contact with anyone diagnosed with a contagious illness in the past 14 days?

• Yes

• No

• Not sure

4. Are you experiencing any chronic health conditions that may require accommodations at work?

• Yes

• No

• Prefer not to answer

5. Have you had any recent injuries or accidents that may affect your work duties?

• Yes

• No

• Prefer not to answer

6. Are there any specific health concerns or accommodations you would like to discuss with the company?

• Yes

• No

• Prefer not to answer

ADDITIONAL COMMENTS

Please provide any additional comments or information related to your health or any specific concerns:

The information provided in this Employee Health Survey will be kept confidential and used solely for assessing and ensuring the health and safety of our workforce. Your cooperation in providing accurate information is essential for maintaining a safe workplace.

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