Gloucestershire County Nhs Occupational Health Service s1

NEW EMPLOYEE HEALTH QUESTIONNAIRE

Working Well Occupational Health Services are provided by 2gether NHS Foundation Trust, for your Organisation.

Have you worked with, or been exposed to, any of the following: (tick as appropriate)

Computers □ Repetitive work □ Known respiratory sensitisers □

Noise □ Vibration □ Known skin sensitisers □

Other hazards □ If “other”, please give details:

Please indicate in which of the listed employments:

Have you ever applied for compensation for any industrial injury/illness? Yes □ No □

If YES, please give details and continue on a separate sheet of paper if necessary:

Are you currently pregnant? Yes □ No □

(This information is required only to protect you under the New and Expectant Mothers at Work Regulations). Please note it is important for your protection that you inform your Manager of your pregnancy as early as possible.

Have you experienced difficulty with reading or written material e.g. dyslexia? Yes □ No □

Do you consider yourself to have a disability? Yes □ No □

If yes, please give details: ………………………………………………………………………………………

(This information is required only to protect you under the Disability Discrimination Act). The Act states that a “person has a disability for the purpose of this Act if they have a physical or mental impairment which has a substantial and long term adverse effect on their ability to carry out normal day-to-day activities”.

Do you have any health condition which you consider could be made worse by working at night?

Yes □ No □

If YES, please give details:

(This information is required only to protect you under the Working Time Directive)

Have you ever suffered from any of the following? (Please tick YES or NO).

If you have answered YES to any of the above, please give details and continue on a separate sheet of paper if necessary:

Have you lived abroad continuously for more than 1 month within the last 5 years? Yes □ No □

If YES, please state which country/ countries involved:

Please now read the following which tells you the further information that we require in order to health clear you for your job. If you have any questions about this – please ring Working Well on 08454 225165 and ask to speak to a Nurse Practitioner about your New Employee Health Screen. It is in your interests to provide this information or contact us as soon as possible so that your start date is not delayed.

The Department of Health (DH) require you to be screened before taking up post in the NHS to establish that you are protected against and not suffering from, certain infectious diseases. If this has been undertaken before in other NHS employment or at university or college you will not need it repeating but we do need documentary evidence of previous screening. We would be grateful therefore if you could provide copies of previous tests as outlined below AS SOON AS POSSIBLE. If you are unable to provide this information, we will need to see you in Working Well to undertake the necessary tests and THIS MAY DELAY YOUR HEALTH CLEARANCE AND START DATE.

For all staff in contact with patients or specimens, we require the following:

Staff from abroad

If you have lived or worked abroad in the last 5 years for more than a month we may also require a chest x-ray and mantoux (skin test). Please indicate on your New Employee Health Questionnare where you have lived and we will advise you.

Additional Health clearance for Exposure Prone Procedures (see definition below)

Exposure prone procedures (EPP) are defined as procedures where injury to you may result in contamination of the patient’s open tissues with your blood. These include work in:

If you are uncertain whether EPP work applies to your post, please contact us.

*Tests to confirm fitness for EPP must be carried out in a UK laboratory on “identified validated samples” (IVS), ie your identity needs to have been confirmed by an occupational health department at the time of the blood sample and this should be indicated on the lab report. If you do not have the above documentation we will need to see you in OH to test you before we can clear you to undertake those parts of your job that involve EPP. When you attend OH please bring photo identification with you e.g. photo driving licence, passport or employee photo identity badge.

It is in your interests to retain all documentation about your vaccinations and immunity checks for future use because there may be a charge for repeat copies.

Please return your completed form with any supporting information to our address on Page 1.

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