PRIVATE AND CONFIDENTIAL STRESS CLAIM … AND CONFIDENTIAL STRESS CLAIM QUESTIONNAIRE ... Was there an abnormal level of sickness or absenteeism in the same ... if measures …

Version 1 – 31 January 2005

Fire Officers’ Association in partnership with Russell Jones & Walker Solicitors

PRIVATE AND CONFIDENTIAL STRESS CLAIM QUESTIONNAIRE

BACKGROUND INFORMATION:

Full name:

Date of Birth:

Address:

Fire and Recue Service:

Present Role and

Area of Work:

Educational and

other Qualifications:

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Employment history since leaving school

Dates Employer

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EMPLOYMENT AND OCCUPATION HISTORY 1. When did you commence your employment with your current employer?

2. Have you any history of psychological, psychiatric or stress related illness prior to

commencing your employment with your current employer?

3. If yes, please provide details.

4. Is your current employer aware of some or all of these conditions? Please explain how. Were they disclosed in interview, on an application form, following a

medical re-examination, in a questionnaire etc.?

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5. Please provide details of all positions held with your current employer together with any promotions. Please explain your duties and responsibilities in each of these posts.

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6. Please provide a list of all relevant personnel within your employer's organisation, particularly

details of your line manager and any other manager whom you work with or report to.

7. Do you believe that your occupation is stressful? If so, why?

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8. What demands were being placed upon you that you considered unreasonable?

9. If your job became stressful, when and why? Please provide as much detail as possible.

10. Do you consider that your workload was more than was normal for the job? - If so, please

give full reasons as to why.

11. Is your work particularly demanding? If so, please explain how?

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12. Are there unreasonable demands being made when compared to those imposed on others in similar jobs? Please provide details.

13. Are other people doing these jobs suffering the same or similar harmful levels of stress? If so,

please provide details.

14. Was there an abnormal level of sickness or absenteeism in the same job or department? If

so, please provide details.

15. Were you working excessive hours? More than 37% hours a week? If so, did you sign a

waiver to waive the application of the Working Time Directive?

Please provide full details of the hours worked together with any documents signed.

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16. Do you consider that your workload was endangering your health? If so, why?

17. What was it about the volume or character of your work that made it particularly difficult or

stressful? Please provide details.

18. What particular pressures of work were you under i.e. time limits, deadlines etc.? Please

provide details.

19. Have you previously made any claim to an industrial tribunal or Court in respect of these

matters? If so, please provide details.

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FIRST EPISODE OF STRESS RELATED ILLNESS 20. When did you consider that you were suffering from the effects of stress in the workplace?

21. What were your symptoms?

22. What in your opinion was/were the problem(s)?

23. Did you tell anybody about the problems you were facing? If so, whom?

24. Did you communicate your symptoms to anybody? If so, whom? (please provide details).

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25. What did you tell your employers at this time? Please provide details

26. Would any of your friends or colleagues have been aware of your problems at this time?

Please provide their names and addresses.

27. Were you ever asked to attend any meetings with anyone about these problems? If so,


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28. Were any of these meetings with your managers, supervisor or boss? When did these meetings take place and what was said in them?

29. Were you ever called to a meeting with Human Resources/Personnel? Please provide details.

30. Were you ever referred to Occupational Health for assessment?

31. If so, what was their assessment and recommendations to your employer?

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32. Did you advise at any time in any of the meetings listed above that you could not cope or words to that effect?

33. Did you advise your employer that work was making you ill?

34. If so, please provide the dates when these meetings took place took place together with a list

of what was discussed.

35. Do you hold any documents such as minutes from such meetings, letters, memoranda

confirming that you conveyed this information to your employer? If so, please provide copies.

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36. Did your employer at this time operate a confidential advice service? Did it include a referral for counselling?

37. Were you referred for counselling by your employer. If not, did you ever receive any

counselling through any outside agency eg your GP? If so, please provide details

38. If you were aware that at a confidential advice service was available and did not seek to

utilise these services, why was this the case?

39. Have you ever consulted your GP?

40. What was your GP's diagnosis?

41. Please provide copy sick notes if possible

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42. Were any changes made to your work environment following any meetings with management and upon the recommendation of personnel, occupational health etc?

43. Did any of these changes improve your situation? If so, in what way?

44. If nothing was done, why not?

45. What in your opinion should have been done to improve your situation?

46. Did you return to work following this first period of stress related illness?

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47. Did any meeting take place prior to your return to work? If so, what was the outcome of the

meeting?

48. Was it agreed at your return to work that anything would be altered in your work environment

so as to ensure that you didn't suffer a further period of stress related illness? If so, please provide details.

49. Have you ever invoked a grievance procedure?

50. If so, what was the outcome?

51. Was dismissal or demotion suggested by your employer and if so, what was your response?

52. At the time that you were suffering from your stress-related illness would any remedial steps

taken by your employers have made any difference to your ill-health by the time they knew/ought to have known it was due to stress at work?

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SECOND OR THIRD EPISODES OF STRESS RELATED ILLNESS 53. Following your return to work, did you suffer a second and third episode of stress related

illness? If so, please provide details.

54. Did you consult your GP and what was his diagnosis on this second or third occasion?

(Please provide copy sick notes for each period of illness if possible).

55. Following the first and second episodes of stress-related illness, why did the second or third

episodes occur?

56. What did your employer do in the meantime to reduce or diminish any stress at work both

prior to and after your return to work?

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57. If nothing changed, why not?

58. Following your return to work, if measures were taken by your employer and you still suffered

a second or third incident of stress related illness, why were the measures taken by your employers not sufficient to avoid the second or third episode?

59. Please give details, facts and matters that can point to the fact that your employers should

have been aware of the fact that you were likely to suffer a further episode of stress related illness following your initial absence due to stress.

60. In respect of any second or third episode of stress related illness, did you utilise the

confidential advice service. If not, why not?

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61. If you were referred to counselling was this through the confidential advice service or through your GP?

62. Please provide details of any counselling you may have received in respect of the second and

third episodes of stress related illness.

63. Did you ever notify your employer that your work was causing you to suffer a re-occurrence of

your illness?

64. If so, what did you advise your employer? Please provide details.

65. Did you advise your employer this was due to the pressures or volume of and character of

your work? If so, please provide details.

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66. Did any meetings take place between yourself and your employer in connection with any second or third episode of stress related illness?

Please provide any minutes, letters or memoranda of any of these meetings, alternatively,

please explain the gist of what was discussed and the outcome of any meetings. 67. What in your opinion should have been done to avoid repetition of your stress-related illness?

68. Did you ever communicate your views to your employer. If so what was their response?

69 Did you ever perceive a situation where you felt powerless and/or trapped? If so, why?

70. Do you ever consider that you were harassed or bullied by either your boss or one of your

immediate superiors or by a member of staff?

If the answer to this is yes, please contact the Fire Officers’ Association to request a bullying

and harassment questionnaire.

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CURRENT SYMPTOMS 71. What are your current symptoms and how does it affect your day to day life and work?

(continue on a separate sheet if necessary).

72. Are you receiving any medication? If so, please provide details.

73. If you are off work now with a psychological condition, have your employers contacted you

and what has been said?

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MISCELLANEOUS DOCUMENTATION 74. Have your employers ever produced any documents such as policy or procedures concerning

the problems of stress at work?

75. Have you been provided with a copy of any of this documentation? If so, please provide

copies.

76. Have any risk assessments been carried out in relation to the conditions of work generally in

your workplace and your own conditions of work and, if so, do you have a copy of those risk assessments?

OTHER PERSONAL FACTORS 77. Have any members of your family had any reason to seek psychiatric advice from a Doctor or

Psychiatrist? If so, please provide details.

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78. Were there any other pressures that might be said to have caused the stress which you were suffering from during the period of stress related illness i.e. have there been any bereavements in the family? Are there any personal circumstances which are likely to have caused anxiety or depression during this period? If so, please provide details.

MEDICAL TREATMENT 79. When did you first seek medical assistance in connection with your stress related symptoms,

and if so from whom? What diagnosis has been made and by whom?

80. Following your completion of this questionnaire the Association may ask its solicitors to

forward to you a number of forms of authority, which they will require in order to access the full extent of any relevant records. We would be obliged if you would complete and sign the consent forms for access to any records from your GP where you received treatment, any hospital where you received treatment, any counselling services where you received treatment, your occupational health notes and your personnel folder.

81. If there is any further information you consider we require in order to fairly assess your claim,


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PRIVATE AND CONFIDENTIAL STRESS CLAIM … AND CONFIDENTIAL STRESS CLAIM QUESTIONNAIRE ... Was there an abnormal level of sickness or absenteeism in the same ... if measures …