CONFIDENTIAL to

King’s College Hospital Occupational Health & Wellbeing Department

Pre-Commencement Health Questionnaire (Postgraduate Research)
Section 1: Project details

Please complete this form as soon as possible following receipt of an offer of study and return it to the Occupational Health & Wellbeing (OH&W) Department at King’s College Hospital as per the instructions in Section 4.

Please answer the questions to the best of your knowledge and by referring to your Project Approval Form; an obviously incomplete form will be will result in it being returned to you and may delay your start date. For assistance in completing the form please refer to Appendix 1: Guidance on completing this form.

Project Title:
Department/Division:
Faculty:
Proposed Date of Registration:
Name of First Supervisor1 (to whom a copy of health assessment outcome should be returned):
Name: / Email address:

Please refer to Section 1 of your Project Approval Form (in particular Statutory Issues: OH Requirements) and indicate which of the following categories best describes the reason for this pre-commencement health questionnaire. Please tick all that apply:

1. / I will have regular direct patient contact and involving exposure prone procedures (e.g. dental and midwifery professionals, those carrying out surgical procedures – please see Appendix 2 for further information)
2. / I will have regular patient contact but no exposure prone procedures (e.g. clinical activities, healthcare workers, physiotherapists, students requiring a KHP Passport)
3. / I will work with patient specimens (eg blood and/or tissue samples)
4. / I will work with genetically modified organisms or biological agents that may pose a hazard to human health
5. / My studies may involve the risk of exposure to human pathogens in the environment (e.g. work involving exposure to soils, surface water systems etc.)
6. / I will work with hazards for which health surveillance is necessary (e.g. respiratory allergens)

1See Section 3 of your Project Approval Form

Pre-commencement health assessment (postgraduate research) Page 4 of 9

F079b-03-HSS King’s College London Aug 2017

CONFIDENTIAL to

King’s College Hospital Occupational Health & Wellbeing Department

Section 2: Your contact details

Student number (7 digit number on page 1 of your Project Approval Form):
Family Name (Block letters): / Mr /Mrs /Ms /Miss /Dr /Professor
Other
First Names:
Date of Birth:
Preferred contact method
Home Address*
Home telephone number
Mobile telephone
Work telephone
Email address
General Practitioner*
Name
Address:
*If your home or GP address changes please inform Occupational Health so that they can amend their records
Have you worked for, or studied at, King’s College London previously? / Yes No
Do you have a contract (or honorary contract) or have your recently worked for, a hospital Trust? / Yes No
If Yes, please provide details:

Section 3: Health Questions

The information you provide is entirely confidential to the Occupational Health & Wellbeing Department and will not be disclosed without your consent.

Please answer those sections relevant to your proposed studies (refer to your Project Approval Form and the Appendices for further assistance). Read and answer the questions carefully and to the best of your knowledge (if you have any queries please contact the Occupational Health & Wellbeing Department).

If you have a disability and have not informed the university prior to this point you may also wish to contact for further advice and support

3a: All applicants - health conditions and disabilities

Do you have a disability or health condition that may benefit from Occupational Health advice to enable you to complete your studies? / Yes No
If you have answered Yes, please provide further information:

3b Applicants undertaking laboratory or environmental studies N/A

If your experimental studies will be in a laboratory or “in the field” please answer the following:
Do you suffer from any allergies? / Yes No
If you have answered “Yes” please provide details:
Have you had a Hepatitis B vaccination*? / Yes / No
If “Yes” please provide an approximate date: / (mm/yyyy)
Have you had a tetanus vaccination*? / Yes No
If “Yes” please provide approximate date: / (mm/yyyy)
Have you had hepatitis A vaccination*? / Yes No
If “Yes” please provide approximate date:
(*If you have documentary evidence of your vaccinations please provide copies) / (mm/yyyy)
Do you have a health condition, or are you taking medication, that may increase your susceptibility to infection? / Yes / No ,
If you have answered “Yes”, please provide further information:

3c Study in Clinical Areas N/A

If your studies are going to bring you into clinical contact with NHS patients or take you into clinical areas in one or more of the College’s partner trusts please answer the following:
All candidates who will access clinical areas or come into contact with trust patients please complete this section:
To assist with this process please attach any documentary evidence of vaccinations or immunity status
Have you been vaccinated against:
Measles* / Yes / No / If Yes, please provide approximate date:
Mumps* / Yes / No / If Yes, please provide approximate date
Rubella* / Yes / No / If Yes, please provide approximate date
Chickenpox* / Yes / No / If Yes, please provide approximate date
Have you lived continuously in the UK for the last 5 years? / Yes / No
If no, please list the countries you have lived in over the last 5 years:
Country / Dates
Do you have, or have you had, any of the following?
A cough lasting more than 3 weeks / Yes / No
Unexplained weight loss / Yes / No
Unexplained fever / Yes / No
Have you ever had tuberculosis or been in close contact (family member or shared a home) with someone who has had tuberculosis? / Yes / No
Have you had a BCG vaccination against tuberculosis*? / Yes / No
If Yes, approximate date:
Candidates who will have clinical contact with patients please also complete the section below (refer to Appendix 2- specific guidance for clinical activities for further information):
Have you ever suspected to have or been diagnosed with one of the following diseases?
Hepatitis B: Yes / No Hepatitis C: Yes / No HIV/AIDS: Yes / No
(please note Health Care Workers have a legal and ethical duty to inform Occupational Health if they suspect or know they are carriers of HIV, Hepatitis B or Hepatitis C)
Have you had a Hepatitis B vaccination*? / Yes / No
If you have answered “Yes” please provide an approximate date:
Will your activities to involve Exposure Prone Procedures (EPP)? (for a definition of EPP please see appendix 2) / Yes / No
If you have answered “Yes”, when do you expect to commence EPP activities?
(mm/yyyy)
*If you have documentary evidence of your vaccinations please provide scanned copies

Section 4 Declaration

Before signing this declaration please ensure that you have completed all the relevant questions as instructed, proving further details as necessary.

1.  I understand my responsibility to notify Occupational Health if I suspect that I am carrying a serious communicable condition (such as Hepatitis B / Hepatitis C / HIV or tuberculosis) if my studies bring me into clinical contact with patients

2.  I acknowledge that my personal details will be stored both electronically and manually by the Occupational Health Service in accordance with the Data Protection Act 1998. (This information will be retained during your period of employment/study and for an additional 40 years to comply with the Control of Substances Hazardous to Health Regulations where applicable.)

3.  If I have any concerns about how this information is handled I am able to contact the Occupational Health & Wellbeing Department at King’s College Hospital

4.  I declare that the information provided by me in this form is true and complete to the best of my knowledge. I understand that any deliberate omission, falsification or misrepresentation in this record will result in an investigation and may lead to disciplinary action by the King’s College London.

Full Name: / Date:

Appendix 1: Guidance on completing this form

Why do you need to complete this form?

Your PhD Supervisor has identified that you will be carrying out tasks that may be affected by your health background (e.g. clinical activities) or may involve potential exposure to hazardous activities or substances (e.g. microbiological agents, allergens or environmental research). In these cases it is important to gain a picture of your current state of health, offer you vaccinations etc. (where appropriate) and to provide advice to yourself and your PhD Supervisor where necessary

Section 1:

Sections 1 and 3 of your Project Approval Form will provide you with the title of the project and First Supervisor details.

Refer to Section 1 of your Project Approval Form under “Statutory Issues” and review the OH Requirements section: this will inform you as to which box(es) to tick. Explanations are given below:

(1)  if you are a dental, midwifery or other clinical professional or student who will be carrying out exposure prone procedures[1]

(2)  if your studies are going to bring you into contact with patients at our partner trusts or take you into clinical areas. This also applies to contact with trust patients outside the clinical setting.

(3)  if you will be handling blood and/or human tissue samples (eg teeth, urine, saliva, biopsies etc)

(4)  if you will be working with infectious biological agents (i.e. hazard group 2 or 3 microorganisms) or genetically modified organisms that may pose a hazard to human health (i.e. GM class 2 and above activities)

(5)  if you will be carrying out environmental studies on or near river, surface or foul water systems, taking soil samples etc.

(6)  if your studies will involve a risk of exposure to respiratory sensitisers such as animal allergens, moulds, wood dust, crystalline silica (eg stone, concrete or brick dust) or other substances that are considered as respiratory sensitisers

(7)  if you have declared a health condition or disability

Section 2:

Please provide your personal, home and General Practitioner (doctor) contact details.

If your home or GP address changes once you have started your studies at the College please inform Occupational Health so that they can amend their records.

Section 3:

Please see below for guidance on which sections to complete. Occasionally it may be necessary to complete more than one section:

Section 3a:

Please complete this section if you have a health condition or disability that you think may affect, or be affected by, your studies. Occupational Health will review the information you provide to determine whether you may need help with adjustments or if there are certain aspects of your proposed studies that could pose a risk to you because of a particular condition. You are welcome to provide information about measures that you have found useful in the past.

Examples of health conditions that may affect, or be affected by, your studies may be:

·  Musculoskeletal problems (e.g. with your back, neck or joints) that could affect you in work.

·  Mental health problems (e.g. stress or depression)

·  Skin problems (e.g. eczema, dermatitis)

·  Diabetes or epilepsy

·  Inflammatory bowel disease

·  Blood borne viruses

·  Heart or breathing problems

·  Taking medication or a health condition that reduces your immunity to infectious disease

·  Any other health condition or disability that affects your mental or physical functional capability

Please note that if Occupational Health believe that you would benefit from support from the university’s Disability Advisory Service they will not contact the service without first seeking your written permission.

If you have dyslexia the university’s Disability Advisory Service will be able to provide you with advice and support: http://www.kcl.ac.uk/campuslife/services/disability/index.aspx

Section 3b:

This section is for experimental work undertaken in the university’s teaching and research laboratories and in the field. Activities that require health assessment are those involving:

·  Intentional work with human blood and human tissue,

·  Intentional work with biological agents and genetically modified organisms,

·  Risk of exposure to human pathogens in the environment (e.g. collecting river water or soil samples)

·  Risk of exposure to respiratory allergens

This section should be completed if you have ticked boxes (3), (4), (5) or (6) in Section 1

Section 3c:

Section 1 of your Project Approval Form under “Statutory Issues” will indicate whether your project involves regular direct contact with NHS patients. If contact is required please complete section 3c - this section also applies to students who will require a KHP Passport.

If you are a practicing healthcare worker please attach documentary evidence of your current clearance status, or validated documentary evidence to confirm your immunity status, and bring originals with you if you are invited for an appointment.

·  The first half of this section should be completed by all those who will have any type of contact with partner trust patients (whether inside or outside a clinical setting).

·  The second half of this section should be completed by those who will have clinical contact with trust patients. Please ensure that you indicate whether or not you will be carrying out exposure prone procedures (EPP). For further information on EPP activities please see Appendix 2.

Declaration

Once you have completed the form (to the best of your knowledge) please email this to King’s College Hospital Occupational Health & Wellbeing Department using the address (subject heading

“Pre-Commencement Health Assessment” and your full name).

Depending upon the information you have provided and the studies you will be undertaking Occupational Health may contact you arrange a telephone or face-to-face appointment. Where vaccinations, blood tests or respiratory health surveillance is needed a face-to-face appointment will be made. If you are invited to an appointment please bring a copy of your Project Approval Form.

Queries

If you have any queries with regards to the information requested in this form please either contact your First Supervisor, the university’s PG Admissions Team or telephone King’s College Hospital Occupational Health & Wellbeing Department on 0203 299 7527/8118 (0900 – 1630hrs) (or e-mail ) as appropriate.