STAFF HEALTH FORM

This form is to be completed by all staff before, OR within four weeks of commencement of employment & forwarded to Human Resources.

ALL FIELDS ARE MANDATORY

Employees Name: Home Address: Postcode: Phone Numbers: Commencement Date: Position: Home: / / Date of Birth: Ward / Department: Suburb: Staff ID Number: Mobile: / /

Have you worked or been cared for in a Health Care Facility outside of Western Australia in the last 12 months? Yes No If yes, where?: Date:

Please attach photocopies of ANY supporting evidence of relevant serology (blood tests) and/or vaccination records, WITHIN FOUR WEEKS of your commencement date, to assist in this assessment.
Disease Have you had the actual disease? Have you ever been vaccinated? Vaccination Course completed? Year? Have you had a blood test/serology? Year?

Have you ATTACHED previous Vaccination and Serology results?

Immunisation / Serology Required? (OFFICE USE ONLY)

Hepatitis B

Yes / No / Unsure

Yes / No / Unsure Year: Yes / No / Unsure Year: Yes / No / Unsure Year: Yes / No / Unsure Year:

Yes / No Year: Yes / No / Unsure Year: Yes / No / Unsure Year: Yes / No / Unsure Year:

Yes / No / Unsure Year: Yes / No / Unsure Year: Yes / No / Unsure Year: Yes / No / Unsure Year:

COPY OF RESULTS ATTACHED: Yes / No

Serology: Yes / No Immunisation: Yes / No Serology: Yes / No Immunisation: Yes / No

Measles Mumps Rubella

Yes / No / Unsure Yes / No / Unsure Yes / No / Unsure

COPY OF RESULTS ATTACHED: Yes / No

Serology: Yes / No Immunisation: Yes / No Serology - Yes / No Immunisation - Yes / No

Tuberculosis

Yes / No / Unsure Year:

Yes / No / Unsure Year:

N/A

N/A

N/A

Quantiferon Gold Testing Recommended: Yes / No

Pertussis (Whooping Cough)

Yes / No / Unsure Year:

Yes / No / Unsure Year:

N/A

N/A

COPY OF RESULTS ATTACHED: Yes / No COPY OF RESULTS ATTACHED: Yes / No

Immunisation Recommended: Yes / No

Chicken Pox

Yes / No / Unsure Year:

Yes / No / Unsure Year:

N/A

Yes / No / Unsure Year:

Serology: Yes / No Immunisation: Yes / No

Employees Signature:

Office Use Only:

MRSA Screening required?: Date Serology Form sent: Referral to IDP & Info letter sent: Date 1 Follow Up Letter sent: Date Assessment Finalised: Date Non-Compliance Recorded:
Updated: December 2011
st

Yes No

Date Screening Form sent: Date Recommended Vaccination Letter sent: Reason: ________________ Date: Date 2 Follow Up Letter sent:
nd

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