OCCUPATIONAL HEALTH DEPARTMENT - Sussex Community
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Occupational Health
Providing an Occupational Health Service
for staff employed by: Western Sussex Hospitals NHS Trust
(Worthing & Southlands Hospitals)
Sussex Community NHS Trust
Sussex Partnership Trust
General Practices and Dental Surgeries
OCCUPATIONAL HEALTH DEPARTMENT
IMMUNISATION & COMMUNICABLE DISEASE – Pre-Employment Screening
|CONFIDENTIAL |
|Please read this form all the way through before starting to complete it |
| |
|The purpose of this form is to ensure, so far as is possible, that you are fit for the post you have applied for, in order to protect your own and others’ |
|health and safety. If you have any difficulties completing this form, or wish to discuss any issues in a confidential setting, please contact the |
|Occupational Health Department for advice. |
| |
|Please read this form carefully and answer all the questions before returning by email to the Occupational Health Department – |
|SC-TR.RecruitmentOccupationalHealth@. This form and its contents will remain confidential to Occupational Health staff. Failure to disclose |
|information or a false declaration may render the individual liable to summary dismissal. There is no need to send a hard copy in the post. |
|Post Applied for | |
|Full/part time/Bank hours per week |Bank |
|Department |East Sussex Healthcare Trust Employee |
|Hospital/Location | |
Section 1
|Surname: | |Title | |
|Forenames: | |Date of birth | |
|Address: | |
| |Post Code |
|Contact No (day) | |Mobile No. | |
|E:mail address | |
|GP |Dr |Address | |
|Tel No of GP | | | |
|Brief details of present and previous employment or training |
| |
|Have you ever worked for or trained in the NHS before? |YES NO |
|If YES please give details |
| |
|From: To: Where: |
|Any other surname by which you have been known? |
| |
Click the ‘mouse’ on the box to indicate YES or NO
|The job involves & there is potential for exposure |YES |
|to: | |
|Have you recently worked or visited for a long | Yes No |
|period of time a country with a high TB rate as | |
|defined by the WHO? | |
|If so, which country and date of visit? | |
|Have you ever been treated for TB? | Yes No |
|Previous BCG: | Yes No |Scar: | Yes No |
|Approximate year: | |
|Skin test date: | |Result: | |
|Please tick if any of the below apply: |
|Loss of appetite and weight loss | |
|Persistent cough | |
|Coughing up blood or blood stained sputum | |
|Unusually tired | |
|Have a fever, most often at night that can result in heavy night sweats | |
|Family history of TB | |
Section 3 (Vaccination History)
|Have you ever had any of the following vaccinations? Please indicate YES/NO or not known. If you know the date or approximate date please indicate. |
|Immunisation |Yes |No |Not known |Dates if known |
| | | | | |
|Hepatitis B primary course | | | | |
|Dose 1 | | | | |
|Dose 2 | | | | |
|Dose 3 | | | | |
|Dose 4 accelerated course | | | | |
|Hepatitis B repeat course if needed | | | | |
|Hepatitis B Booster | | | | |
|Known non-responder to Hepatitis B vaccine | | | | |
|Measles (single doses) | | | | |
|Rubella (German measles) (single doses) | | | | |
|Measles, Mumps and Rubella (MMR) | | | | |
|Dose 1 | | | | |
|Dose 2 | | | | |
|Varicella (chicken pox) | | | | |
|Dose 1 | | | | |
|Dose 2 | | | | |
|Hepatitis A | | | | |
|Typhoid | | | | |
|Polio | | | | |
|Tetanus | | | | |
|Diphtheria | | | | |
|Diphtheria, Tetanus & Polio combined (DTP) | | | | |
|If you have a record of your BCG (Tuberculosis) vaccination or TB skin test please supply or your start date may be delayed. |
|Have you had any of the following illnesses? |Yes |No |Not known |Dates |
| (a) varicella (chicken pox)? | | | | |
| (b) shingles? | | | | |
| (c) rubella (German measles)? | | | | |
| (d) measles? | | | | |
| (e) mumps? | | | | |
Section 4
| |
|If your job involves any of the following: Direct patient care, House-keeping/cleaning/disposal of rubbish or clinical waste, Laboratory work, or any |
|other work that may require you to wear latex (rubber) gloves please answer the following questions. |
| |
|(Natural Rubber Latex is found in many products in the healthcare setting. For example, gloves-examination and surgical, elastic bandages, ambu bags, |
|adhesive tape etc. It is also found in the home. For example, household work gloves, condoms, balloons etc. |
|Medical history |
|Do you have a sensitivity to any latex products? | Yes No |
|If Yes: describe the reaction | |
|What caused the reaction? | |
|Do you have a personal or family history of eczema, asthma or hay fever? | Yes No |
|Do you have any allergic reaction if you eat any of the following: |
|Banana | |
|Avocado | |
|Kiwi Fruit | |
|Chestnuts | |
|other nuts | |
|any other foods | |
|Please specify: |
| |
|Do you have any of the following when exposed to latex? |
|Dermatitis/eczema | |
|Urticaria/hives/nettle-rash | |
|Asthma | |
|Hay-fever | |
|Tight chest | |
|Coughing | |
|Sneezing | |
|Rhinitis/runny nose | |
|Itchy or runny eyes | |
|Anaphylactic reaction | |
|Have you had any local reaction or swelling/itching following | Yes No |
|medical/dental examination where latex gloves used? | |
|If Yes please give brief details | |
|Does your current occupation involve exposure to latex? | Yes No |
Section 5
|Have you suffered any of the following during the last year? If yes, please|Yes |No |Not known |Dates |
|include the date and any treatment you had or are still having: | | | | |
|Diarrhoea and / or vomiting | | | | |
|Skin infections affecting hands, arms, face or head | | | | |
|Sties, boils or septic fingers | | | | |
|Discharge from eyes, ears, gums or mouth | | | | |
|Recurring skin / ear problems | | | | |
| | | | | |
|Recurring bowel disorder | | | | |
|Skin problems caused by food or latex | | | | |
|Breathing problems caused by food or latex | | | | |
|Contact in the last 21 days with anyone at home or abroad who may have been suffering from typhoid or | Yes No |
|paratyphoid | |
IF YOU NEED TO GIVE ANY FURTHER INFORMATION
PLEASE USE THIS SPACE
NIGHT WORKERS HEALTH SCREENING
If you are required to work three hours or more between 10.00 pm and 7.00 am, as part or your normal work, you will be classified as a “Night Worker” under the “Working Time Regulations”. You will, therefore, be entitled to a voluntary health screening. If you would like to pursue this, please contact the Occupational Health Department on (01273 446056) or by e-mail:
sc-tr.occupationalhealthadmin@
Section 6
CONSENT AND DECLARATION
I agree to attend a medical examination, if necessary, and will give my permission to the Occupational Health Department to request any information that may be required from my General or other Medical Practitioner. I understand that this information will be used to assess fitness to work in the applied post. I certify that I have answered all questions truthfully and that I am not aware of any medical reason that would prevent me from carrying out the duties required of me in the post for which I am applying.
I DECLARE THAT ALL OF THE ABOVE STATEMENTS AND INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE.
Name – Print
Signature
Date
| | | |
| |FOR OCCUPATIONAL HEALTH USE ONLY – (DO NOT COMPLETE) | |
| | | |
| |Date received – (Date stamp) | |
| | | |
| |...................................................................................................................................... | |
| | | |
| |Form received by: | |
| | | |
| |name ..................................................... signed ............................................. date | |
| | | |
| |Fit | |
| | | |
| |...................................................................................................................................... | |
| | | |
| |Request further information | |
| |...................................................................................................................................... | |
| | | |
| |...................................................................................................................................... | |
|1 |We need further information relating to your health questionnaire. | |
|2 |Please arrange an appointment with the Nurse Adviser for pre-employment health interview/ vaccination check. Please bring the following to| |
| |the appointment if you have: Documentary evidence of TB screening / BCG/ record of any immunisations received and blood test results | |
|3 |Please arrange an appointment with the Occupational Health Doctor | |
|4 |You are advised to have a routine Hepatitis B booster | |
|5 |Your form is returned herewith. Please complete where indicated and return in the envelope provided. | |
|6 |Please telephone the Occupational Health Department on the above number once you have a start date from Human Resources and book a routine| |
| |vaccination check | |
|7 |Please provide UK lab report detailing your immunity to Varicella(chicken pox) Rubella(German Measles) Hepatitis B antibodies | |
| |as indicated in bold | |
|8 |Please provide evidence of 2 MMR vaccines or a UK lab report detailing your immunity to Measles. | |
| |Please provide documentary evidence of your BCG (TB) vaccination/scar or TB screening. If you do not have this information please | |
|9 |telephone the Occupational Health Department on the above number and arrange an appointment with the Practice Nurse or Nurse Advisor.. | |
| |If classified Exposure Prone Procedure (EPP) Worker please provide an Identified Validated Sample report of the following: | |
|10 | | |
|*a |Your Hepatitis B immune status by way of a validated UK laboratory report | |
|*b |Evidence of Hepatitis B surface Antigen (HBsAg) negative by way of a validated UK laboratory report | |
|*c |Evidence of Hepatitis C antibody negative by way of a validated UK laboratory report | |
|*d |Evidence of HIV status by way of a validated UK laboratory report | |
|*e |Prospective employees designated as EPP workers should bring photographic identity i.e. passport or driving licence if attending for | |
| |appointment in case of blood test. | |
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