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New Starter Clinical Form

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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. Your records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations. Your records will be held on file for the purposes of processing your request only and for no longer than is necessary, however your records may be subject to internal clinical audits. Your records may also be used to cross reference and ascertain your fitness should you register with other clients of Healthier Business UK Ltd.

Personal Information

(Please note: Your name should be in full, as appearing on the NMC register and passport)

Medical History

All Staff groups complete this section:

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

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

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

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

Medical History Continued

Have you suffered from any of the following?

Methicillin Resistant Staphylococcus Aureus(MRSA)*

Clostridium Difficile (C-Diff)*

Chicken Pox or Shingles

Have you ever had chicken pox or shingles*

BBV (Blood Brone Virus)

Have you ever had BBV*

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?*

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

Tuberculosis Continued

Do you have any of the following?

A cough which has lasted for more than 3 weeks*

Unexplained weight loss*

Unexplained fever*

Have you had tuberculosis (TB) oe been in recent contact with open TB*

Immunisation History

Have you had any of the following immunisation?

Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)*

Polio*

Tetanus*

Hepatitis B (If Yes is ticked please give dates below)*

Proof of Immunity Please send the following

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

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
We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)
Certificate of "two" MMR vaccinations or proof of a positive antibody for Rubella and Measles
You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above

Proof of Immunity (Please send the following)
EPP Candidates Only

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

Evidence of Hepatitis B Surface Antigen Test (Inc. 'e' antigen and DNA viral loads if applicable.) Report must be an identified validated sample. (IVS)
Evidence of a Hepatitis C antibody Test (Inc. Hepatitis C RNA/PCR if applicable). Reports must be an identified validated sample. (IVS)
Evidence of a HIV I and ll antibody test (Inc. DNA viral loads if applicable). Reports must be an identified validated sample. (IVS)

Exposure Prone Procedures

Will you role involve Exposure Prone Procedures*

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;

Declaration