Clinical Staff 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.

Title

First Name *

Surname

Date Of Birth *

Home Telephone Number

Work Telephone Number

Mobile

Home Address *

Postcode *

GP Address *

GP Postcode *

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

Proof of Immunity (EPP Candidate Only)

(Please send the following)

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)

Exposure Prone Procedures

Will your role involve Exposure Prone Procedures *

Yes

The General Data Protection Regulation (GDPR) (EU) 2016/679

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, Specialist’s 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/

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? *

Yes

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? *

Yes

If you consent to recommendations being made to your employer/agency do you wish to see a copy of the recommendations prior to their release to your employer/agency? *

Yes

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.

Name *

Signature *

Date *

Clinical Staff Questionnaire

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

(NEW STARTER CLINICAL FORM)

CONFIDENTIAL

Medical History

All staff groups complete this section

MRSA

Chicken Pox or Shingles

BBV (Blood Borne Virus)

Tuberculosis

Immunisation History

Have you had any of the following immunisations

Proof of Immunity

(Please send the following)

Proof of Immunity (EPP Candidate Only)

(Please send the following)

Exposure Prone Procedures

The General Data Protection Regulation (GDPR) (EU) 2016/679

Consent

All staff groups complete this section

Declaration