Pre Employment Occupational Health Form

CONFIDENTAL RECRUITMENT BUREAU/ BANK OFFICE (delete as applicable)

Occupational Health Chase Farm Hospital The Ridgeway Enfield Middlesex EN2 8JL 020 8375 1137 FAX 020 8375 1047 EMAIL [email protected]

CLEARANCE TO ___________________________________________ DATE ___________________________________________

CANDIDATES SHOULD NOT TERMINATE THEIR PRESENT EMPLOYMENT BEFORE BEING INFORMED OF HEALTH CLEARANCE.

Enfield Primary Care Trust

PRE-EMPLOYMENT HEALTH QUESTIONNAIRE SURNAME

MAIDEN NAME (if applicable)

Dr/Mr/Mrs/Miss/Ms FIRST NAMES

NEXT OF KIN Name Relationship Tel NATIONAL INSURANCE No

DATE OF BIRTH

POST APPLIED FOR:

COUNTRY OF BIRTH

DEPT _______________________________ SITE ________________________________

HOME ADDRESS

TEL

Home Work Mobile FAMILY DOCTOR

Does the post involve night work?

YES


NO


If YES, is it permanent?

YES


NO


or Bank shifts?

YES


NO


Expected date of commencement: Have you previously worked for this organization? YES
NO


Name Address

If YES, when did you leave?

Are you aware if the post applied for will involve any of the following? (Tick all that apply) Possible exposure to blood or other substances of human origin




Handling patients




Handling food




Possible exposure to methylmethacrylate




Driving




Possible exposure to plaster dust




Possible exposure to cytotoxic drugs




Possible exposure to chemicals




Possible exposure to ionizing radiation




Possible exposure to anaesthetic gases




Possible exposure to noise




Are you allergic/sensitive to any foods or substances? If YES, please give details

YES




NO




Are you allergic/sensitive to any natural rubber products e.g. gloves If YES, please give details

YES




NO




Have you visited or arrived from any country other then USA/Canada/ Australia/New Zealand or EEC countries within the past year?

YES




NO




PREVIOUS WORKING HISTORY To enable us to organize your occupational health care, please list all jobs you have had within the past 5 (FIVE) years. Please include information about any special hazards or health risks to which you were exposed. 1

FROM

TO

JOB DESCRIPTION/SPECIALITY

HAZARD/HEALTH RISK

HAVE YOU HAD ANY OF THE FOLLOWING? Please answer YES or NO, giving details and dates. If in doubt, please answer DON’T KNOW. 1.

Skin conditions (including persistent spots or dermatitis)? _______________________________________________

2.

Discharge or infection of the ears or defects of hearing? ________________________________________________

3.

Asthma or hay fever, any allergic conditions and sensitivity to antibiotics or other medicines? _____________________________________________________________________________________________

4.

Recurrent sore throats? __________________________________________________________________________

5.

Chest problems (i.e. persistent cough or infections)? ___________________________________________________

6.

Tuberculosis? _________________________________________________________________________________

7.

Heart problems? _______________________________________________________________________________

8.

High blood pressure? ____________________________________________________________________________

9.

Severe headaches (including migraine)? ____________________________________________________________

10. Blackouts (including fits and epilepsy)? ______________________________________________________________ 11. Mental illness (including depression, nervous breakdown or eating disorders)? If YES, give details and treatment. _____________________________________________________________________________________________ 12. Neck or back problems? _________________________________________________________________________

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13. Bending or lifting problems? ______________________________________________________________________ 14. Rheumatism, arthritis or painful joints? ______________________________________________________________ 15. Varicose veins or foot problems? __________________________________________________________________ 16. Stomach problems? _____________________________________________________________________________ 17. Kidney or bladder problems? ______________________________________________________________________ 18. Eye conditions (including injuries or defects of vision)? _________________________________________________ 19. Diabetes? _____________________________________________________________________________________ 20. Blood disorders, sickle cell, jaundice or liver problems? _________________________________________________ 21. Any conditions requiring attendance at hospital (including operations and injuries)? _____________________________________________________________________________________________ 22. Any absence from work, college or school due to ill health during the past 2 years? If YES, please give details and state number of days. _____________________________________________________________________________________________ 23. Do you consider yourself to have a disability? If YES, give details. _____________________________________________________________________________________________ 24. Do you/have you required any modification or additional equipment in your workplace to enable you to do your job? If YES, give details. _____________________________________________________________________________________________ 25. Are you at present having any form of treatment from a doctor? If YES, give details. _____________________________________________________________________________________________ 26. Do you smoke? If YES, please state number per day. __________________________________________________ 27. Would you consider that you have or have had a drink problem? __________________________________________ 28. What is your weekly intake of alcohol? ______________________________________________________________ 29. Height? __________________________ Weight? ___________________________ Does it remain steady? Yes/No 30. Do you have any medical conditions not listed on this form? ______________________________________________ If YES, give details ______________________________________________________________________________________________

FEMALE CANDIDATES ONLY This information is required to ensure you will not be exposed to any substances/ hazards which may be harmful to your unborn baby Please state if you know or suspect you may be pregnant ________________________________________________

ALL CANDIDATES Have you had? Chicken pox Mumps

YES YES





NO NO





German Measles Measles

VACCINATION HISTORY HEPATITIS B course dates

YES YES





NO NO





ANTIBODY TEST 1.____________________________ DATE ______________________ 2.____________________________ 3.____________________________

DATE OF BOOSTERS

1.____________________________

NOT VACCINATED

(tick box if appropriate)

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RESULT ______________________

HAVE YOU HAD THE FOLLOWING TESTS OR VACCINATIONS? Please answer YES or NO, giving details and dates. If in doubt, please answer DON’T KNOW. B.C.G. ________________

Yes/No DATE ________________

Heaf/Mantoux

Yes/No DATE

Measles/Mumps/Rubella (MMR) ________________

Yes/No DATE ________________

Measles

Yes/No DATE

Polio

Yes/No DATE of COURSE ________________

Rubella (German Measles)

Yes/No DATE ________________

Rubella Antibody Test

Yes/No DATE ________________

Tetanus

Yes/No DATE of COURSE ________________

Varicella (Chicken Pox) Antibody Test

BOOSTERS ________________

BOOSTERS ________________

Yes/No DATE ________________

Triple vaccine as a child (Diptheria/Tetanus/Whooping cough) Yes/No DATE ________________

EXPOSURE PRONE PROCEDURES (EPPs) If your job involves EPPs, (see attached list) please provide VALIDATED documentary evidence of the following: HEPATITIS B - either a current satisfactory immunity status (antibody levels >100) or non-infectivity status (negative surface antigen less than 6 months old). HEPATITIS C - either a current negative antibody status or a negative RNA (less than 6 months old).

CLEARANCE TO COMMENCE WORK WILL NOT BE GIVEN UNTIL THIS INFORMATION IS RECEIVED BY OCCUPATIONAL HEALTH. I declare I have answered the questions on this form honestly and fully and I am not aware of any other physical or mental disability that will or may affect my working capacity before retiring age. I am aware that false or incomplete statements may affect my appointment of future employment. The Trust actively implements the Disability Discrimination Act (1995). SIGNATURE ____________________________________

DATE ____________________________________

Please ensure you have read, completed and signed both this page, and page 7.

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OFFICE USE ONLY To Be Completed By Occupational Health HEIGHT

WEIGHT

VISION

KEYSTONE

Distance Near Middle

Refer for further assessment?

URINE

B/P

PULSE

WITHOUT GLASSES R.6/ L.6/ R. L R. L.

WITH GLASSES (OR CONTACT LENSES) R.6/ L.6/ R. L. R. L.

Yes/No

Colour Vision ____________________________

RECOMMENDED VACCINATION PROGRAMME Sharps Policy Accident Policy


Polio

Course/Booster

YES


NO


Tetanus

Course/Booster










NURSE’S EXAMINATION

Heaf/Mantoux







Ears ____________________________________

B.C.G.







Teeth ____________________________________

Rubella Vaccine







Skin ____________________________________

Rubella Titre







COMMENTS/ADVICE GIVEN (specify)

Varicella Titre







Hepatitis B Course







Hepatitis B Booster







Hepatitis B Titre







PAPER SCREENING Satisfactory evidence of Hepatitis B immunity

YES


NO


NOT ENCLOSED


N/A


Satisfactory evidence of Hepatitis C non-infectivity













Nothing declared to indicate unsuitability for employment




Request applicant to contact OH




OH will contact applicant




Correspondence with GP/Specialist




Referred to OH Physician




SIGNATURE ____________________________________

DATE ____________________________________

FIT FOR EMPLOYMENT




SIGNATURE ____________________________________

DATE ____________________________________

CLEARANCE SENT TO _______________________________________________________________________________

BASELINE SCREENING FIT FOR EMPLOYMENT




SIGNATURE ____________________________________

DATE ____________________________________

CLEARANCE SENT TO _______________________________________________________________________________

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DEPARTMENT OF OCCUPATIONAL HEALTH SPECIAL GUIDANCE FOR HEALTHCARE WORKERS INVOLVED IN 'EXPOSURE PRONE PROCEDURES (EPP's)

DEFINITION OF EPP'S "Exposure prone procedures are those where there is risk that injury to the worker may result in the exposure of the patient's open tissue to the blood of the worker. These procedures include those where the worker's gloved hands may be in contact with sharp instruments, needle tips and sharp tissues (spicules of bone or teeth) inside the patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times". Expert Advisory Group on Hepatitis B August 1993.

IF YOU ARE INFECTED OR CONSIDER YOURSELF TO BE A CARRIER OF HEPATITIS B/C OR THINK YOU MAY HAVE BEEN INFECTED WITH HIV, YOU HAVE AN ETHICAL DUTY TO INFORM OCCUPATIONAL HEALTH.

EXAMPLE OF EMPLOYEES PERFORMING EPP’S MEDICAL STAFF All Surgeons, Obstetricians and Gynaecologists Accident and Emergency Doctors Cardiologists performing cardiac catheterisation or angiography Dentists All Bank Doctors/Locum Doctors/Clinical Assistants if working in the above specialities

NURSING STAFF Theatre/Day Surgery Staff involved in ‘scrub procedures’ i.e. Nurses, ODA’s/ODP’s Accident and Emergency Nurses Midwives and Midwifery students Dental nurses/dental students (certain tasks) Hepatitis B carriers who are ‘e’ antigen positive or ‘e’ negative with a viral load, which exceeds 103 genome equivalents per ml, are not permitted to perform EPP’s. (HSC2000/020) Health Care Workers who are Hepatitis C virus RNA positive are not permitted to perform EPP’s (HSC2002/010) HIV infected workers are not permitted to perform EPP’s. HSG(94)16

HEPATITIS B Any person applying for one of the above posts MUST provide documented evidence of either a current satisfactory immunity status (antibody levels >100) OR non-infectivity status (negative surface antigen less than six months old).

HEPATITIS C Any person applying for one of the above posts MUST provide documented evidence of either a current negative antibody status OR a negative RNA (less than six months old).

CLEARANCE TO COMMENCE WORK WILL NOT BE GIVEN UNTIL THIS INFORMATION IS RECEIVED BY OCCUPATIONAL HEALTH. Venepuncture, the giving of injections and the setting up of intravenous lines is not considered to be ‘exposure prone procedures’.

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TUBERCULOSIS (TB) Please return this completed form with your health questionnaire. FAILURE TO DO SO MAY DELAY COMMENCEMENT OF YOUR EMPLOYMENT Due to an increase in reported cases of TB in the UK, it is necessary to ask you the following questions.

1.

Is this your first post within the NHS? YES/NO (delete as appropriate)

2.

Have you come to the UK from any other country within the past 5 years? YES/NO (delete as appropriate) If YES please state which country/countries ______________________________________________________________________ Have you travelled to any country outside the UK recently and stayed longer than 2 months? YES/NO (delete as appropriate) If YES please state which country/countries ______________________________________________________________________

3.

Have you recently been in contact with anyone suspected or known to have tuberculosis? YES/NO

4.

(delete as appropriate)

Have you any symptoms compatible with tuberculosis i.e. persistent cough/fever and/or weight loss/ heavy sweating at night? YES/NO (delete as appropriate)

Name (PRINT) ________________________________________________________________

Signature ________________________________________________________________ Date ________________________________________________________________

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