Appendix 6
Confidential Work Experience/Shadow
Pre-Placement Health Questionnaire
Last Name: ______
First Name: ______
Date of Birth: ______
Current Age: ______
Home Address: ______
Post Code: ______
Telephone No: ______
Emergency Contact Telephone No: ______
Work Experience Placement Area: ______
Placement Dates: ______
YES / NO1.Do you have any Health problems which may prevent you
from undertaking this placement or could be made worse
by undertaking this placement?
2. Have you spent more than 12 weeks outside the UK in the
Last 12 months? If Yes, where?
3. Have you received two doses of the Measles, Mumps, Rubella (MMR) vaccine? (Official documentary evidence is required prior to clearance for a placement, for example a print out from your GP Surgery is required).
4. Have you ever had Chicken Pox?
5. Have you been in contact with any infectious disease in the past 4 weeks?
6. Please state any other information that you feel may be relevant
Please Turn Over
Confidential Work Experience/Shadow
Pre-Placement Health Questionnaire
If the answer to questions 1, & 5 is ‘yes’, your placement co-ordinator will send you the full occupational health screening form to complete and return to the Occupational Health Department for their clearance prior to you undertaking the placement. If you answer Yes to question 2, it is important that you write which country you visited as this would determine what further action is required.
This can take up to 6 – 8 weeks and the placement cannot be undertaken until clearance is received.
Please note: If you have suffered from an episode of diarrhoea and/or vomiting less than 48 hours before your work experience/shadowing is due to start including whilst on placement, then you should not attend your placement and must telephone the Occupational Health Department for advice and information. You must then contact your placement sponsor to make them aware of the situation.
The Trust reserves the right to terminate any placements with immediate effect if something not previously disclosed should come to light which could potentially put individuals within the Trust at risk.
Please note - By providing this information to the Trust you confirm that the information given by you is true, accurate and complete in all respects.
Signature______
Date______
Parent/Guardian’s signature if under18______
Date ______
If any of the above circumstances change from the time of completing the form to the time of placement you must inform the appropriate department immediately.
/ Chief Executive: Joe HarrisonActing Chairman: Simon Lloyd