Professional Documents
Culture Documents
The information on this form will remain confidential to the Occupational Health Service and will be held securely within the department unless otherwise agreed by you. The information will be assessed by an Occupational Health practitioner who will advise Human Resources of the outcome of the assessment. You may be asked to provide additional information or asked to attend the Occupational Health Department prior to commencing employment. When fully completed, please return this form to the Occupational Health Department at the site below. Failure to complete and return the questionnaire will result in it being returned to you and may delay your starting date. Post Appointed to: .. Department: ... Human Resources contact name: .... . E-mail address: ....... Hospital: . Site: .
Mr/Mrs/Miss/Ms/Dr/Prof/Sir/Rev
Male/Female
Please indicate if you have ever worked for any of the following organisations and the year you left:
Date of Birth:
Surname:
(Block Capitals)
Bromley PCT
First Names:
Home Address:
Post Code:
Email:
Greenwich PCT
Year left:
Immunis ation
Yes
Yes
No
Yes
No
Measles
Mumps
Rubella
Chicken Pox
Hepatitis B
If your job will involve exposure prone procedures, you must attach copies of identified sample test results of HBsAg and antiHbs from a UK laboratory
Primary Course
Boosters
Hepatitis C
HIV
Tuberculosis
BGC vaccination
Heaf/Mantoux test
Result
Any applicant whose work involves exposure prone procedures (EPP) who commenced EPP work after August 2002 must provide valid documentation of their Hepatitis C status. Applicants commencing EPP work after March 2007 must provide valid documentation of their HIV status. This documentation must be returned with this health questionnaire. Any successful applicant who has not provided appropriate documentation will not be permitted to undertake EPP work until valid results have been obtained through the Occupational Health Department. Please attach copies of all immunisation details and blood test results and bring photo identification to all Occupational Health appointments
If you answer Yes to any of the questions below, please give dates and details and continue on a separate sheet of paper if necessary.
YES
Are you currently receiving treatment of any kind from your GP, hospital specialist, or other health practitioner (including complementary therapists) awaiting or undergoing investigations?
NO
Have you ever had an illness, medical problem or injury that may currently affect your ability to work in the post for which you have applied?
Have you ever had any health problems that have caused you difficulty with sitting, standing, bending, lifting, carrying, or working with a computer? Have you ever had any mental health problems (Including anxiety, depression, nervous breakdown, stress, eating disorders, self-harm, addictions)? Have you ever had rhinitis, hayfever, asthma or any chest/breathing problems?
Have you ever had any skin problems e.g. eczema, psoriasis, recurrent skin infections, allergic rashes?
Have you had any days away from study or work due to illness or injury in the last 2 years? Please give number of days and reasons to the best of your recollection.
A failure to declare a known condition or any current/ongoing investigation which may result in risk or harm being put to patients or other members of staff, will result in action being taken against you and referral to your regulatory body.
Date
Fit for post Fit for EPP Fit for post but not fit for EPP until OH clearance Fit with adjustments Adjustment details Further information required
Pre-employment health interview Pre-employment medical assessment Human Resources Clearance Sent to: