Annual Health Dec

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

(ANNUAL REVIEW FORM)

CONFIDENTIAL

Before health clearance is given for employment you may be contacted by Healthier Business UK Ltd and may need to be seen by an occupational health advisor or physician with gained consent. We may recommend adjustments or assistance following an assessment to enable you to carry out your proposed duties safely and effectively. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice. Our aim is to promote and maintain the health of all individuals in the workplace: staff, service users and third parties. Your record will be held on file for the purposes of processing your request and for no longer than is necessary. Your records may also be subject to internal clinical audits. Your records may also be used to cross reference and ascertain your fitness should you register with other clients of Healthier Business UK Ltd.

1 Personal Information

Personal Information

Title*

Full Name

Work Tel

Home Tel

Mobile

D.O.B

2 Address

Container

House Number and Street Name

County

Country

City

Post Code

3 GP Address

Container

GP Surgery Name

House Number and Street Name

County

City

Country

Post Code

4 Changes to your health

Changes to your health

*Please ensure to tick one box only**

I confirm that I have reviewed my health questionnaire and there has been no changes to my health in the past year*

Y

N

I confirm that I have reviewed my health questionnaire and I have listed the changes below*

Y

N

5 Medical History

Medical History

Have you come into contact with any BBV’s (Blood Bourne Virus) since you were initially screened by Occupational Health including Needle Stick Injuries?*

Y

N

6 Medical History Continued

Medical History (continued)

Have you suffered from any of the following? *

methicillin resistant staphylococcus aureus (MRSA)*

Y

N

Clostridium difficile (C-Diff)*

Y

N

If you have indicated YES to any of the above questions you must provide further details, including dates, treatment and details of condition. Failure to do so will result in the form being returned/rejected.

Additional Information

7 Tuberculosis

Tuberculosis

Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2016)

Have you lived outside the UK or had an extended holiday outside the UK in the last year?*

Y

N

If you answered YES to the above, please list all the countries that you have lived in/visited over the last year, including holidays and vacations. This MUST include duration of stay and dates or this form will be rejected.

List Countries

Have you had a BCG vaccination in relation to Tuberculosis? *

Y

N

If you answered yes, please state when

8 Tuberculosis Signs & Symptoms

Tuberculosis Signs & Symptoms

Do you have any of the following?

A cough which has lasted for more than 3 weeks*

Y

N

Unexplained weight loss*

Y

N

Unexplained fever*

Y

N

Have you had tuberculosis (TB) or been in recent contact with open TB*

Y

N

If you have indicated YES to any of the above questions you must provide further details, including dates, treatment and details of condition. Failure to do so will result in the form being returned/rejected.

Additional Information (If you have answered yes to any questions above please provide additional information below)

9 UK General Data Protection Regulation (UK GDPR)

UK General Data Protection Regulation (UK GDPR)

All information supplied by you will be held in confidence by Healthier Business UK Ltd. Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. Your data may also be cross referenced should you have registered with other clients of Healthier Business UK Ltd. Your personal data may be required to be seen by an occupational health advisor or physician; however it will not be shown, nor their contents shared with anyone - including Managers, Human Resources Advisors, GP’s, Specialists or third party’s - without your explicit consent. You have the right of erasure (the right to be forgotten), refusal of consent and withdrawal of consent without detriment (withdrawal of consent can be exercised at any stage of the process). The only exceptions to this may be a court order for release of records in a judicial dispute or where there is a public responsibility obligation. Further information regarding your rights under GDPR can be found on the following:

https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/

If you wish to have sight of our privacy policy, please send your request to support@hbcompliance.co.uk

10 Consent

Consent

Consent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed. You have the right to withdraw your consent at any stage of the process, either verbally or in writing. Further information regarding consent is available on the ‘Candidate Screening Leaflet’.

All Staff Groups Complete this section *

Do you consent to this questionnaire and your immunisation reports being assessed by an Occupational Health Advisor for the purpose of providing a Fitness to Work Certificate?*

Y

N

Do you consent to our Occupational Health Advisors speaking with you regarding any declaration you may have made relating to your medical history?*

Y

N

Do you consent to our Occupational Health Advisors making recommendations to your employer/agency to assist with your ability to carry out your perspective role?*

Y

N

11 Declaration

Declaration

I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

Full Name

Annual Health Dec

Form successfully restored

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

Personal Information

Container

Container

Changes to your health

Medical History

Medical History (continued)

Tuberculosis

Tuberculosis Signs & Symptoms

UK General Data Protection Regulation (UK GDPR)

Consent

Declaration

Signature

Your form has been submitted