Health Dec

Occupational Health Medical Questionnaire

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

(NEW STARTER CLINICAL FORM)

CONFIDENTIAL

Due to the nature of the role you have applied for we need to carry out an assessment of a new starter health questionnaire – even if you have been employed in UK health services before. The health of each candidate is considered individually and a decision regarding fitness for work in the prospective job role will be based on the functional effects of any underlying health condition/disability/impairment as well as health service requirements for fitness and immune status.

Before health clearance is given for employment you may be contacted by telephone from a clinician at Healthier Business UK Ltd, however you may also need to be seen by an occupational health advisor/specialist or physician, arrangements for face to face consultations will be arranged by your employer or agency. 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 records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations. Your records will be held on file for the purposes of processing your request only and for no longer than is necessary, however your records may 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

Home Tel:

Work Tel:

Mobile:

2 Your Address

Container

House Number and Street Name

County

Country

City

Post Code

3 GP Address

Container

GP Surgery Name

House Number and Street Name

Country

County

City

Post Code

4 Medical History

5 Medical History Continued

Medical History Continued

Chicken Pox or Shingles

Have you ever had chicken pox or shingles?*

Y

N

Medical History Continued

BBV (Blood Borne Virus)

Have you ever come into contact with any BBV’s? Including Needle Stick Injuries?*

Y

N

6 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.

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

Y

N

7 Tuberculosis Continued

Tuberculosis Continued

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

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

If yes, please can you provide the date of your last vaccine?

8 Immunisation History

Immunisation History

Have you had any of the following immunisations?

Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)*

Y

N

Polio Vaccination*

Y

N

Tetanus Vaccination*

Y

N

Hepatitis B Vaccination*

Y

N

If "Yes" to Hepatitis B Vaccination, please give dates:

	Date 1	Date 2	Date 3
	Date 1	Date 2	Date 3
Course	Date 1	Date 2	Date 3
Booster	Date 1	Date 2	Date 3

9 Proof of Immunity (Please send the following)

Proof of Immunity (Please send the following)

Varicella	You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity
Tuberculosis	We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)
Rubella, Measles & Mumps	Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella and Measles
Hepatitis B	You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above

10 Proof of Immunity (Please send the following) EPP Candidates Only

Proof of Immunity (Please send the following) EPP Candidates Only

Hepatitis B

Surface Antigen

Evidence of Hepatitis B Surface Antigen Test (Inc. ‘e’ antigen and DNA viral loads if applicable

Report must be an identified validated sample. (IVS)

Hepatitis C

Evidence of a Hepatitis C antibody test (Inc. Hepatitis C RNA/PCR if applicable)

Reports must be an identified validated sample. (IVS)

HIV

Evidence of a HIV I and II antibody test (Inc. DNA viral loads if applicable)

Reports must be an identified validated sample. (IVS)

11 Exposure Prone Procedures

Exposure Prone Procedures

Will your role involve Exposure Prone Procedures?*

Y

N

12 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

13 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

14 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

Form successfully restored

Occupational Health Medical Questionnaire

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

Personal Information

Container

Container

Medical History

Medical History Continued

Medical History Continued

Tuberculosis

Tuberculosis Continued

Immunisation History

Proof of Immunity (Please send the following)

Proof of Immunity (Please send the following) EPP Candidates Only

Exposure Prone Procedures

UK General Data Protection Regulation (UK GDPR)

Consent

Declaration

Signature

Your form has been submitted