Pre-employment Health Screening Questionnaire

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Pre-employment Health Screening Questionnaire Powered By Docstoc
					                                                                                                       FORM 2




Pre-employment Health Screening Questionnaire
To be completed by the applicant and returned to:
Atos Origin, Southwark PCT, Unit 2 Meadowcourt,
Hayland Street, Sheffield S9 1BY
Surname:                                                        ORGANISATION: To be completed by
                                                                recruiting officer before issue to applicant.
Forename:                                                       Title of Job Applied For:
Title:
                                                                Existing Staff? Yes/No
Previous Names:
                                                                Recruiting Officer:
Date of Birth:
                                                                Address:
Address:


                                                                Post code:
Post code
                                                                Tel No of Recruiting Officer:
Daytime telephone number where you can be contacted:
Home/Work/Mobile


IMPORTANT:
All successful applicants are required to complete this form. It is very important that you give full and
clear details of your health. A lack of details means that we would have to wait to contact you to
confirm the missing details. This delays your appointment. This form and the details on it will not be
released without your informed consent.
Please list previous occupations (include any breaks) for the last 5yrs only, in date order (present
occupation first)
      Date                Employer               Occupation          Exposure to hazards, e.g. noise,
                                                                      dust, fumes, manual handling
 From            To




Do you have a disability, which requires any special equipment, environment etc? This question is
asked so that the Occupational Health Service can assist you and your new manager in providing for
any special needs you may have when you commence work (this ensures that the organisation
complies with the Disability Discrimination Act 1995).
Yes/No
Details:




                                            Southwark PCT New Starter Health Dec version 2 13 March 2007
 Do you have, or have you suffered from any of the following (please circle YES or NO):

Back/neck/limb ache/ joint pain/arthritis etc that limits your normal movement?           YES       NO

Epilepsy/fits/blackouts/ fainting etc?                                                    YES       NO

Diabetes or other endocrine disorders, Jaundice or other blood disorders?                 YES       NO

Current or previous Chest disease/angina/ heart attack/ Heart problems etc?               YES       NO

Asthma or other breathing problems/conditions?                                            YES       NO

High blood pressure/giddiness/prolonged headaches or migraine?                            YES       NO

Do you have any problems relating to shift working or night duty?                         YES       NO

Eyesight problems not corrected by glasses or contact lenses?                             YES       NO

Hearing impairment requiring assistance or special equipment a work or any recurrent      YES       NO
or persistent ear infections or other ENT problems?

Allergies to dusts, chemicals, foods, drugs or other substances?                          YES       NO

Latex/rubber allergy or any other skin related dermatitis/ eczema type condition or       YES       NO
other skin disease?

Psychiatric ill health, including diagnosed conditions, treatment or ongoing              YES       NO
therapy/support?

Bulimia/anorexia/eating disorders?                                                        YES       NO

Depression/anxiety reactive or endogenous even if mild?                                   YES       NO

Gynaecological/Bladder or Kidney problems where this affects your ability to              YES       NO
work and results in frequent absence?

Do you have any health problems relating to night work or shift pattern working?          YES       NO

Do you have, or have you had, any health problems which resulted in a change or           YES       NO
restriction in your professional activities?

Other not mentioned above                                                                 YES       NO




                                             Southwark PCT New Starter Health Dec version 2 13 March 2007
  Where you have circled YES, please give full details below. Please include details of the illness
  e.g. dates of occurrence, diagnosis, treatment, GP visits, inpatient/outpatient treatment,
  medication past or present, surgery and any time off sick for the problem and for how long.

    SAMPLE PROBLEM
 I had back strain 2yrs ago after lifting a box. Saw the GP and he gave me Brufen for two weeks. Stayed off work
 for two weeks. No problem since, I did need physiotherapy and went to the hospital for this but I was discharged
 two weeks later, I haven't had any time off work since.
 Problem:




 Problem:




 Problem:




 DO NOT FORGET TO PROVIDE FULL DETAILS, THESE ARE ESSENTIAL TO THE ASSESSMENT OF THIS FORM

Any additional health issues should be documented on a separate page and attached to this form.
The NHS does not have any policies, which prevent individuals, who are carriers of infectious diseases,
from being employed. Except where any infectious disease has the potential to be transferred to patients
through Exposure Prone Activities. All information is confidential and will not be released without your
informed consent.
Do you have or are you a carrier of any of the following conditions and of any not listed?
Hepatitis A/B/C?                                                                           YES            NO
 HIV/Aids?                                                                                     YES        NO
 Persistent MRSA?                                                                              YES        NO
 Tuberculosis?                                                                                 YES        NO
 Tropical Disease e.g. malaria, typhoid etc?                                                   YES        NO
 Other                                                                                         YES        NO

Where you have circled YES please give full details below. Please include details of the illness e.g. dates
of occurrence, diagnosis, treatment, GP visits, inpatient/outpatient treatment, medication past or present,
surgery and any time off sick for the problem and for how long.
  DETAILS




                                                Southwark PCT New Starter Health Dec version 2 13 March 2007
Part Two: Immunisation and Investigation History
Part One: - to be completed by all staff
Have you ever had any of the following immunisations or tests?
Please indicate YES or NO and give dates and test results where known.
Immunisation                           No Yes Date                   Test Result
Tetanus
Poliomyelitis
Rubella (German Measles)
TB Test (Heaf, Tine, Mantoux)
BCG (TB Immunisation)
Diphtheria
Hepatitis A
Hepatitis B * See Part 2.
Injection no.1
Injection no.2
Injection no.3
Hepatitis B Titre Level
Hepatitis B Surface Antigen
Booster Dose
Titre following Booster
HIV Blood test *See Part 2
Hepatitis C Blood test *See Part 2
History of Chickenpox
History of Chickenpox vaccination
MMR I
MMR II
              I confirm that the information supplied is correct to the best of my knowledge.
Signature of applicant:                                 Date:

Part Two – It is a condition of appointment to Exposure Prone Procedure (EPP) roles that
evidence of successful immunisation against TB and Hepatitis B are provided. Evidence of
absence of infection to Hepatitis C and HIV also require to be provided. Please complete part 1
above and provide documented laboratory results with this health declaration form if possible.
Official Stamp of General Practitioner or OHS         Please ensure that you supply a copy of your
                                                      Hepatitis B titre / Hepatitis C result or Ensure that
                                                      your General Practitioner or Occupational Health
                                                      Service confirm your titre result by signing and
                                                      stamping the space to the left.




                                            Southwark PCT New Starter Health Dec version 2 13 March 2007
      All applicants should read the following statement then sign and date the declaration
 DECLARATION:
 I certify that the answers on this form are, to the best of my knowledge, correct. I understand that
 giving false or withholding information could affect the terms of my contract and may lead to my
 dismissal.

 I understand that the information I have provided in this health declaration form may be released to
 your occupational health service provider, Atos Origin. I also understand that Atos Origin may
 contact me by telephone – or request I attend an appointment to assess my suitability for this specific
 job role – and will provide a report regarding my suitability to Southwark PCT. I agree that Atos
 Origin, if required, may contact my GP/Hospital Specialist for a report on my health.


 Signature of Applicant:                                                                 Date:

 GP/Personal Doctor
 Name:
 Address:

 Post Code:
 Phone Number:

 Hospital Specialist
 Name:
 Address:

 Post Code:
 Phone Number:

For your information, personal data provided on this form will be held and used in accordance with the Data
Protection Act 1998 and treated as confidential. This data may be verified by reference to information held by
others
Access to Medical Reports Act 1988
Under the terms of the above act you have the right to withhold your consent to Atos Origin to apply to your
General Practitioner / Hospital Specialist for medical information.
If you give your consent you have the right to see the information in the report before it is sent to Atos Origin.
You have 21 days from the date of the letter notifying you that a report has been requested, in which to ask your
General Practitioner / Hospital Specialist to let you see the report. They will tell you if you cannot see any part of
the report for professional medical reasons. If you are given access to the report your General Practitioner /
Specialist will not send it to Atos Origin until you give your consent.
If you regard any information in the report as incorrect or misleading you can ask, in writing, for it to be
amended. (Please note, if your General Practitioner / Specialist does not accept that the information is incorrect
or misleading, they are not required to make any amendment, but in these cases they will invite you to prepare a
written statement on the disputed information, which will be attached to the report when it is sent to Atos Origin).
Subject to the provision of the Act, you have the right to see information about your medical condition for up to
six months after it has been sent to Atos Origin. If your General Practitioner /Specialist gives you a copy of the
report, they may charge you a reasonable fee to cover the cost of supplying it.
   I wish to see any such report before it is sent to Atos Origin.                               Yes          No

Data Protection Act 1998
Access to Medical Reports Act 1988 does not affect an individual’s right to make an access request in
relation to their personal data in accordance with the DPA 1998.



                                                  Southwark PCT New Starter Health Dec version 2 13 March 2007