New Starter Clinical Form

CONFIDENTIAL


Due to the nature of the role you have applied for we need to carry out a complete 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 Healthier Business UK Ltd and may need to be seen by an occupational health advisor or physician with gained consent. 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 partie

PERSONAL INFORMATION

This title field is required.
This first name field is required.
This surname field is required.
This date of birth field is required.
This home telephone no field is required.
This mobile field is required.
This home address line 1 field is required.
This home address line 2 field is required.
This post code field is required.
This GP address line 1 field is required.
This GP address line 2 field is required.
This post code field is required.

MEDICAL HISTORY

All Staff groups complete this section:

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?*

Yes No
This field is required.

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?*

Yes No
This field is required.

Are you having, or waiting for treatment (including medication) or investigations at present?*

Yes No
This field is required.

Do you think you may need any adjustments or assistance to help you to do the job?*

Yes No
This field is required.

MEDICAL HISTORY CONTINUED

Have you suffered from any of the following?

methicillin resistant staphylococcus aureus(MRSA)*

Yes No
This field is required.

clostridium difficile (C-Diff)*

Yes No
This field is required.

CHICKEN POX OR SHINGLES

Have you ever had chicken pox or shingles*

Yes No
This field is required.

BBV (BLOOD BRONE VIRUS)

Have you ever had chicken pox or shingles*

Yes No
This field is required.

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?*

Yes No
This field is required.

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

Yes No
This field is required.

TUBERCULOSIS CONTINUED

Do you have any of the following?

Yes No
This field is required.
Yes No
This field is required.
Yes No
This field is required.
Yes No
This field is required.

IMMUNISATION HISTORY

Have you had any of the following immunisation?

Yes No
This field is required.
Yes No
This field is required.
Yes No
This field is required.
Yes No
This field is required.

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

(Allowed Type(s): .pdf, .doc, .docx)

This upload field is required.

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)

(Allowed Type(s): .pdf, .doc, .docx)

This upload field is required.

Rubella, Measles & Mumps*

Certificate of "two" MMR vaccinations or proof of a positive antibody for Rubella and Measles

(Allowed Type(s): .pdf, .doc, .docx)

This upload field is required.

Hepatitis B*

You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above

(Allowed Type(s): .pdf, .doc, .docx)

This upload field is required.

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)

(Allowed Type(s): .pdf, .doc, .docx)

This upload field is required.

Hepatitis C*

Evidence of a Hepatitis C antibody Test (Inc. Hepatitis C RNA/PCR if applicable). Reports must be an identified validated sample. (IVS)

(Allowed Type(s): .pdf, .doc, .docx)

This upload field is required.

HIV*

Evidence of a HIV I and ll antibody test (Inc. DNA viral loads if applicable). Reports must be an identified validated sample. (IVS)

(Allowed Type(s): .pdf, .doc, .docx)

This upload field is required.

EXPOSURE PRONE PROCEDURES

Yes No
This field is required.

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 thier 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), withdrawal of consent and refusal of consent without detriment. 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.

RECOMMENDATIONS

I understand that following this assessment, recommendations may be provided to assist my health at work;

I give consent for the Healthier Business UK Ltd to make recommendations and for my employer/agency to provide these recommendations to my placement
I would like to see a written copy of any recommendations Healthier Business UK Ltd may make before my employer/agency provide them to my placement
This field is required.

DECLARATION

I will inform my employer if I am planining 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.

This name field is required.
This date field is required.
This signature field is required.
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