WORK HEALTH ASSESSMENT
CONSENT AND DECLARATION
TO BE COMPLETED BY THE APPLICANT FOLLOWING OFFER OF EMPLOYMENT
Your answers to this questionnaire will be confidential to the Occupational Health team and will not be given to anyone else without your written permission.
The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job.
Our aim is to promote and maintain the health of all people at work. Before health clearance is given for employment you may be contacted by Occupational Health and may need to be seen by an Occupational Health advisor or physician.
I agree to attend a medical examination if necessary. I consent to the outcome of this paper screening regarding my fitness for the post being communicated to Medical HR (specific health problems will remain confidential to the Occupational Health Department).
Full Name: / Date:Personal Details / Start Date:
(Medical HR use only)
Please mark with an X as appropriate.
Surname: / Title:First Names: / Gender: / Male:
Any other surname(s) used: / Female:
Date of Birth:
Address:
Post Code: / Home Telephone Number:
Email Address: / Mobile Telephone Number:
Job Title (new): / Location: / St Richard’s Hospital:
Department (new): / Worthing Hospital:
Recruiting Manager’s Name: / Southlands Hospital:
Have you ever been employed by the NHS before? / Yes: / No:
Are you currently employed by Western Sussex Hospitals NHS Foundation Trust? / Yes: / No:
Please mark with an X as appropriate.
If yes, please give details:
2. Have you ever had any illness/impairment/disability which may have been caused or made worse by your work? / Yes: / No:
If yes, please give details:
3. Are you having, or waiting for treatment (including medication) or investigations at present? If your answer is yes, please provide further details of the condition, treatment and dates. / Yes: / No:
If yes, please give details:
4. Do you think you may need any adjustments or assistance to help you to do the job? / Yes: / No:
If yes, please give details:
To be completed by THOSE STAFF whose job may involve NIGHT WORK
1. Have you ever worked nights before? / Yes: / No:2. If yes, during this time did you ever suffer from any health problems associated with working at night e.g. difficult blood sugar control if diabetic, respiratory symptoms if asthmatic, night-time seizures with epilepsy, severe sleep disturbance? / Yes: / No:
3. Do you consider yourself fit to undertake night work? / Yes: / No:
To be completed by FOOD HANDLERS e.g. all catering staff, nurses, housekeepers, therapy staff etc involved in the handling or preparation of food
If yes, please give details:
2. Are you a carrier of any other food borne disease or parasitic infection? / Yes: / No:
If yes, please give details:
3. In the last 21 days, have you been in contact with anyone, at home or abroad who may have been suffering from typhoid or paratyphoid fever? / Yes: / No:
If yes, please give details:
4. At present are you suffering from:
§ Recurrent or persistent skin infections? / Yes: / No:
If yes, please give details:
§ Recurrent attacks of diarrhoea? / Yes: / No:
If yes, please give details:
5. Do you suffer from:
§ Chronic infections of the ear, eyes, nose, throat or gums? / Yes: / No:
If yes, please give details:
§ Dental problems? / Yes: / No:
If yes, please give details:
TO BE COMPLETED BY ALL APPLICANTS
LATEX ALLERGY
1. Have you been diagnosed as suffering from a latex (natural rubber) allergy? / Yes: / No:If yes, please give details:
2. Have you ever had a reaction following contact with products containing latex? / Yes: / No:
If yes, please give details:
3. Have you every had a reaction after eating the following foods: Banana, Avocado, Kiwi, Chestnut, Potato, Mango, Tomato / Yes: / No:
If yes, please give details:
4. Do you have a history of contact dermatitis when wearing gloves? / Yes: / No:
If yes, please give details:
5. Have you ever had a severe allergic reaction in the presence of latex (e.g. wheezing, facial swelling, collapse)? / Yes: / No:
If yes, please give details:
Failure to provide the following information will delay health clearance for work
In which country were you born?
Tuberculosis (TB)
Have you lived / worked abroad in the last five years? / Yes: / No:Have you had any contact with TB? / Yes: / No:
Have you got a persistent cough? / Yes: / No:
Do you suffer from night sweats? / Yes: / No:
Have you had unexplained weight loss? / Yes: / No:
Have you had a BCG vaccination? / Yes: / No:
Do you have a scar? / Yes: / No:
Have you had a Mantoux test? / Yes: / No:
If yes: / Date: / Result:
Vaccination History/Blood Test Results
You must check with your GP/previous Occupational Health Department for dates and results before completing this section.
Please supply copies of vaccination history/blood test results for the following:
Tetanus
Poliomyelitis
Typhoid
Chicken Pox
MMR
Measles
Mumps
Rubella
Hepatitis A
Hepatitis B
If you have previous blood results and/or documented evidence of relevant vaccinations please supply a copy when you submit this form.
Exposure Prone Procedures (EPP)
Exposure Prone Procedures (EPP) are those procedures where the worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissue (e.g. spicules of bone or teeth) inside a patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times.
EPP staff include: All surgeons (including FY1 and FY2 doctors with a rotation into one of the EPP areas), dental staff, theatre staff and midwives.
As part of the Western Sussex Hospitals NHS Trust pre-employment screening policy it is necessary for you to provide documentary evidence of the below results. If this is not available before commencement of post you will be required to have bloods taken for the necessary tests and should contact the Occupational Health Department as soon as possible on the telephone numbers below.
EPP staff MUST provide documentary evidence of Hepatitis B, Hepatitis C and HIV status.
This must be an identified validated sample (IVS) taken in the UK.
If results are not available you will be tested in this department and health clearance for EPP work will be delayed until these results are processed.
Health clearance for EPP work cannot be given until these results are available
Date of HIV antibody test / Copy of result attached:Date of Hepatitis B surface antigen test / Copy of result attached:
Date of Hepatitis C antibody test / Copy of result attached:
Please email this completed form to
Please note in the email subject line for which is applicable for your application:
Work Health Assessment – St Richard’s Hospital
or
Work Health Assessment – Worthing/Southlands Hospital
Alternatively, please return this completed form to the hospital you will be working at:
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St Richard’s Hospital
Occupational Health
Western Sussex Hospitals NHS Foundation Trust
St Richard’s Hospital
Spitalfield Lane
Chichester
West Sussex
PO19 6SE
Direct Line (01243) 831478
Internal Ext 2403
Fax (01243) 831479
Worthing and Southlands Hospitals
Occupational Health
Western Sussex Hospitals NHS Foundation Trust
Worthing Hospital
Lyndhurst Road
Worthing
West Sussex
BN11 2DH
Direct Line (01903) 285276
Internal Ext 5276
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