OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE (NEW STARTER CLINICAL FORM)

Due to the nature of the role you have applied for we need to carry out a complete 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 Team A5 Ltd and may need to be seen by an occupational health advisor or physician with gained consent. 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.

Email Address :*

Title*

Surname*

First names*

DOB*

Home Tel :*

Format: 000-0000-0000.

Work Tel :*

Format: 000-0000-0000.

Mobile*

Format: 000-0000-0000.

Home Address*

GP Address*

Medical History*

Rows	YES	NO
Do you have any illness/impairment/disability (physical or psychological) which may affect your work?
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?
Are you having, or waiting for treatment (including edication) or investigations at present?
Do you think you may need any adjustments or assistance to help you to do the job?

Medical History (continued) - Have you suffered from any of the following?*

Rows	YES	NO	Date
methicillin resistant staphylococcus aureus (MRSA)
clostridium difficile (C-Diff)

If you have indicated YES to any of the above questions you must provide further details in additional information section, failure to do so will result in the form being returned/rejected.

Additional Information (If you have answered YES to any questions above please provide additional information below, including dates, treatment and details of condition)

Chicken Pox or Shingles*

Rows	YES	NO	Date
Have you ever had chicken pox or shingles?

Rows	YES	NO
Have you ever come into contact with any BBV's? Including Needle Stick Injuries?

Tuberculosis - Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2016)*

Rows	YES	NO	Date
Have you lived outside the UK or had an extended holiday outside the UK in the last year?
Have you had a BCG vaccination in relation to Tuberculosis?

If you have answered YES to the above, please list all the countries that you have lived in/visited over the last year, including holidays and vacations. This MUST include duration of stay and dates or this form will be rejected.

Tuberculosis (continued) - Do you have any of the following?*

Rows	YES	NO
A cough which has lasted for more than 3 weeks
Unexplained weight loss
Unexplained fever
Have you had tuberculosis (TB) or been in recent contact with open TB

Additional Information (If you have answered YES to any questions above please provide additional information below)

Immunisation History - Have you had any of the following immunisations?*

Rows	YES	NO	Date
Triple vaccination as a child (Diptheria/Tetanus/Whooping cough)
Polio
Tetanus
Hepatitis B (If YES is ticked please give dates below)

Hepatitis B (If YES is ticked please give dates below)*

Rows	1	2	3
Course
Boosters

Exposure Prone Procedures*

Rows	YES	NO
Will your role involve Exposure Prone Procedures

All information supplied by you will be held in confidence by Team A5 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 Team A5 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, Specialist’s or third party’s - without your explicit consent. You have the right of erasure (the right to be forgotten), withdrawal of consent and refusal of consent without detriment. 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.

I give consent for the Team A5 Ltd. to make recommendations and for my employer/agency to provide these recommendations to my placementI would like to see a written copy of any recommendations Team A5 Ltd. may make before my employer/agency provide them to my placement

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*

Signature*

Date*

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE (NEW STARTER CLINICAL FORM)

CONFIDENTIAL

Personal Information

All staff groups complete this section

The General Data Protection Regulation (GDPR) (EU) 2016/679

Recommendations

Declaration