CONFIDENTIAL

MANDATORY FIELD TRIP/PLACEMENT/WORK ABROAD

HEALTH DECLARATION FORM FOR PARTICIPATING STUDENTS AND STAFF

The University has a statutory duty to ensure, asfar as is reasonably practical, the health, safety and welfare of their employees and students when taking part in field trips/placements/work abroad.

  1. To participate in a field trip/placement/work abroadyou must complete and sign the following health declaration form, read any relevant documents e.g. risk assessments and hand it to your Activity Organiser. The Activity Organiser may refer any staff/students to Occupational Health where they require further advice.
  2. Failure to declare a condition will result in your travel cover (if provided by the University) being declared invalid e.g. if you are charged for any necessary medical treatment you will have to pay the costs yourself.
  3. If you have a pre-existing health problem needing regular or intermittent treatment, you will need to inform the Activity Organiser (usually the person in charge of the activity) at the beginning of the course. It is unacceptable to do this on the day of the activity or days shortly before the activity as this may be the cause of exclusion from the activity rather than your actual condition.
  4. In the majority of referred cases the information provided by you in this “Health Declaration”, will be sufficient, when referred to Occupational Health to pass you as fit to participate in the activity. Some students however may be required to discuss information contained in their Health Declaration in further detail with Occupational Health and may subsequently require a medical examination.
  5. It may be necessary for you to obtain a fitness to travel letter from your General Practitioner (GP). Please note any medical details supplied will remain confidential to Occupational Health, no information will be provided to others without your informed consent.
  6. Vaccinations are often required when travelling overseas. It is the applicants own responsibility to check their vaccination status is fully up to date and any necessary vaccinations needed for overseas travel have been completed prior to departure. Occupational Health does not carry out vaccinations for overseas travel for students.
  7. Please note the following questions refer to your current situation and not to just your long term health e.g. a temporary inner ear infection may affect questions g), h) and i). Any information provided will be held in confidence and only for the necessary duration.
  8. Health Conditions do not mean you will be stopped from an activity unless there is a serious risk to yourself or others.

IF YOU DO NOT RETURN THE HEALTH DECLARATION FORM WITHIN THE TIMESCALES DEFINED BY YOUR COLLEGE/SCHOOL/DEPARTMENT YOU MAY BE EXCLUDED FROM THE FIELD TRIP/PLACEMENT/WORK ABROAD.

Surname: / Forename(s):
Student / Staff Number: / Tel/Mob:
Proposed date(s) of travel:
Activity/Destination: / Date of Birth:
College/School/Department: / Course:
Address:

Health Questions:

Do you have, or have you had any of the following conditions: Please place a cross  in the relevant box.

a / Asthma/Bronchitis/Hay Fever / Yes / / No /
b / Epilepsy/Fits/Fainting/Blackouts / Yes / / No /
c / Allergies / Yes / / No /
d / Severe headaches/Migraine / Yes / / No /
e / Heart/Circulatory / Yes / / No /
f / Diabetes / Yes / / No /
g / Travel sickness / Yes / / No /
h / Vertigo / Yes / / No /
i / Hearing impairment / Yes / / No /
j / Vision impairment / Yes / / No /
k / Infectious disease - If no longer infectious answer ‘No’ / Yes / / No /
l / Mobility difficulty/wheelchair user / Yes / / No /
m / Mental Health issue / Yes / / No /
n / Chronic Fatigue Syndrome / Yes / / No /
o / Pregnant now, or have been pregnant in the last six months / Yes / / No /
p / Any other condition, medical condition, illness, disability or surgery (in last 6 months) which may affect your ability to undertake the activity / Yes / / No /

If you answered ‘Yes’ to any of the above answers please give more detail here:

______

Student/Staff Declaration

I certify that my answers to the questions are complete, accurate and to the best of my knowledge no information has been withheld. I understand that if this is later shown not to be the case it may result in my suitability for the activity being withdrawn. I understand the risks associated with the activity.I am aware that I must inform the Activity Organiser if there are any changes to my condition, medical condition or disability while at University.

Signed……………………………………………………………Date ………......

Print Name ………………………………………………………

TO BE COMPLETED BY OCCUPATIONAL HEALTH STAFF ONLY

The above person is FIT / UNFIT to participate in the activity.

Name: ______Signature: ______Date: ______

CONFIDENTIAL

Form OHFT Issue 001 - 01/09/2010