Ansa Clinical Staff Questionnaire

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE
Due to the nature of the role you have applied for we need to carry out an assessment of a new starter health questionnaire – even if you have been employed in UK health services before. The health of each candidate is considered individually and a decision regarding fitness for work in the prospective job role will be based on the functional effects of any underlying health condition/disability/impairment as well as health service requirements for fitness and immune status.

Before health clearance is given for employment you may be contacted by telephone from a clinician at Healthier Business UK Ltd, however you may also need to be seen by an occupational health advisor/specialist or physician, arrangements for face to face consultations will be arranged by your employer or agency. We may recommend adjustments or assistance following an assessment to enable you to carry out your proposed duties safely and effectively. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice. Our aim is to promote and maintain the health of all individuals in the workplace: staff, service users and third parties. Your records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations. Your records will be held on file for the purposes of processing your request only and for no longer than is necessary, however your records may be subject to internal clinical audits. Your records may also be used to cross reference and ascertain your fitness should you register with other clients of Healthier Business UK Ltd.
Personal Details
Name

First Name Last Name
Title
DOB

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

County
Medical History

All staff groups complete this section
Do you have any illness/impairment/disability (physical or psychological) which may affect your work?

Yes No
Have you ever had any illness/impairment/disability whichmay have been caused or madeworse by your work?

Yes No
Do you think you may need any adjustments or assistance to help you to do the job?

Yes No
Have you suffered from any of the following?
methicillin resistantstaphylococcus aureus (MRSA)

Yes No
If yes, when?
clostridium difficile (C-Diff)

Yes No
If yes, when?
If you have indicated yes to any of the above questions you must providefurther details in additionalinformation section, failure to do so will result in the form beingreturned/rejected
Have you had a BCG vaccination in relation to Tuberculosis?

Yes No
If Yes, When??
Tuberculosis Continued
Do you have any of the following

Yes No
A cough which has lasted for more than 3 weeks

Yes No
Unexplained weightloss

Yes No
Unexplained fever

Yes No
Have you had tuberculosis (TB) or been in recent contact with open TB

Yes No
Additional Information (If you have answeredyes to any questions aboveplease provide additional information below)
Immunisation History
Have you had any of the following immunisations

Yes No
If yes, when

Month Day Year
Date
Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)

Yes No
If yes, when

Month Day Year
Date
Polio

Yes No
If yes, when

Month Day Year
Date
Tetanus

Yes No
If yes, when

Month Day Year
Date
Hepatitis B (If Yes is tickedplease give dates below)

Yes No
If yes, when

Month Day Year
Date
Courses
Boosters
Proof of Immunity(Please send the following)
Varicella

You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity
Tuberculosis

We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)
Rubella, Measles & Mumps

Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella and Measles
Hepatitis B

You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above
Proof of Immunity(Please send the following) EPP Candidates Only
Hepatitis B Surface Antigen

Evidence of Hepatitis B Surface Antigen Test (Inc. ‘e’ antigen and DNA viral loads if applicable

Report must be an identified validated sample. (IVS)
Hepatitis C

Evidence of a Hepatitis C antibody test (Inc. Hepatitis C RNA/PCR if applicable)

Reports must be an identified validated sample. (IVS)
HIV

Evidence of a HIV I and II antibody test (Inc. DNA viral loads if applicable)

Reports must be an identified validated sample. (IVS)
Exposure Prone Procedures
Will your role involveExposure Prone Procedures

Yes No
UK General Data Protection Regulation (UK GDPR)
All information supplied by you will be held in confidence by Healthier Business UK Ltd. Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. Your data may also be cross referenced should you have registered with other clients of Healthier Business UK Ltd. Your personal data may be required to be seen by an occupational health advisor or physician; however it will not be shown, nor their contents shared with anyone - including Managers, Human Resources Advisors, GP’s, Specialists or third party’s - without your explicit consent.

You have the right of erasure (the right to be forgotten), refusal of consent and withdrawal of consent without detriment (withdrawal of consent can be exercised at any stage of the process). The only exceptions to this may be a court order for release of records in a judicial dispute or where there is a public responsibility obligation.

Further information regarding your rights under GDPR can be found on the following: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-

gdpr/individual-rights/

If you wish to have sight of our privacy policy, please send your request to support@hbcompliance.co.uk
Consent
Consent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed.

You have the right to withdraw your consent at any stage of the process, either verbally or in writing.

Further information regarding consent is available on the ‘Candidate Screening Leaflet’.
All staff groups complete this section
Do you consent to this questionnaire and your immunisation reports being assessedby an Occupational HealthAdvisor for the purpose of providing a Fitness to Work Certificate?

Yes No
Do you consent to our Occupational Health Advisors speaking with you regarding any declaration you may have made relating to your medical history?

Yes No
Do you consent to our Occupational Health Advisors making recommendations to your employer/agency to assist with yourability to carry out your prospective role?

Yes No
Declaration
I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return.

I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.
Name
Date

Month Day Year
Date
Signature

Clear
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OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

Personal Details

Medical History

Have you suffered from any of the following?

Tuberculosis Continued

Immunisation History

Proof of Immunity(Please send the following)

Proof of Immunity(Please send the following) EPP Candidates Only

Exposure Prone Procedures

UK General Data Protection Regulation (UK GDPR)

Consent

All staff groups complete this section

Declaration