OCCUPATIONAL HEALTH SERVICES DEPARTMENT

CONFIDENTIAL WORK HEALTH ASSESSMENT

Please complete ALL sections of this document as fully and as accurately as possible,
remembering to sign and date the form on the last page.

Please use a BLACK BIRO AND BLOCK LETTERS, and return the completed form by email to
[email protected]. Information given on this form is confidential to the
Occupational Health team and will not be shared with anyone else without your permission.

Remember to attach copies of all your work related blood results and immunisation details.

PERSONAL DETAILS

Mr / Mrs / Miss / Dr / Ms / Professor / Other * Male / Female * (*Circle as applicable)

Surname Forenames

Previous surname Date of birth

(If applicable)

Position you have been offered by our Trust Department you will be joining

Home address

Post Code
Tel no (Home): Email Address:

Mob:
Name and Address of your General Practitioner

Post Code: Tel No:

Have you been OR are you YES (please state your job title & Year of employment)
currently employed by the Trust? NO

In keeping with the clinical diagnosis and management of tuberculosis, and measures for
its prevention and control (NICE 2006), please answer the following –
Do you have a cough which has Unexplained Unexplained weight
lasted for more than 3 weeks? Yes No fever? Yes No loss? Yes No

Have you had tuberculosis (TB) or been in recent contact with open TB? If Have you lived
yes, please give details continuously in the UK Yes No
for the last 5 years?
If no, please list all of the countries that you have lived in over the last 5 years

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Surname Forenames DOB:

PLEASE ANSWER THE QUESTIONS BELOW -

1 Have you a medical condition that may impact on your ability to undertake your YES NO
new role?
2 Are you currently receiving / waiting for any treatment or medication for any YES NO
medical condition that may impact on your ability to undertake your new role?
3 Have you ever had any health conditions which may have been caused, or made YES NO
worse, by work?
4 Have you a health condition that may require adjustments or accommodations to YES NO
the workplace or job role in order for you to undertake your new role?
5 Have you had an illness or absence lasting 4 weeks or more in the past 2 years YES NO
and / or had more than 3 separate incidences of absence in the past year?
6 Have you any medical condition that may require regular absence from the work YES NO
place in order to facilitate treatment or investigations?
7 Have you been previously ill health retired from any job? YES NO

If you have answered any questions as above, please give further details

If you DO NOT have any underlying health conditions that could be affected by your work,
please confirm your answer by signing the statement below –
I am not aware of any health condition or disability which might impair my ability
to undertake effectively the essential functions of the position which I have been
offered

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Surname Forenames DOB:

All clinical staff must attach documentary evidence of ALL the details below. If you are unsure about your
Immunisations or Exposure Prone Procedure (EPP) status, please contact Occupational Health on: 07834
093899.

IF RESULTS ARE NOT AVAILABLE YOU WILL BE TESTED IN THE DEPARTMENT AND HEALTH
CLEARANCE FOR EPP WORK WILL BE DELAYED UNTIL THESE RESULTS ARE PROCESSED. You will be
asked to show formal photographic ID i.e. valid driver’s licence, passport or NMUH ID for this procedure.
This is to comply with the Department of Health’s standard for Identified Validated samples (IVS).

YES NO DATES / RESULTS

IMMUNISATIONS & BLOOD TESTS
1.
Hepatitis B course 2.
3.
Hepatitis B Booster
Hepatitis B Antibody
HIV antibody
Hepatitis B Surface antigen
Measles, Mumps & Rubella, Antibody OR Dates 1.
of MMR vaccination 2.
Hepatitis C antibody

TB skin test e.g. Mantoux test OR blood test Please state result

BCG vaccination (protection against TB)

Varicella (chicken pox) IgG blood test OR Dates of 1.

immunisation against Varicella 2.
Date of last Chest X-ray

Diphtheria, Tetanus & Polio vaccination 1

(including Booster dates) 2
3
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE

I declare that the answers to all questions are true and complete to the best of my knowledge and belief.
Signature Date

FOR OFFICE USE ONLY

Date Category Signature

3 of 3

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