Occupational Health Department

Occupational Health Providing an Occupational Health Service for staff employed by: Western Sussex Hospitals NHS Trust (Worthing & Southlands Hospitals) Sussex Community NHS Trust Sussex Partnership Trust General Practices and Dental Surgeries

OCCUPATIONAL HEALTH DEPARTMENT

IMMUNISATION & COMMUNICABLE DISEASE – Pre-Employment Screening

CONFIDENTIAL Please read this form all the way through before starting to complete it

The purpose of this form is to ensure, so far as is possible, that you are fit for the post you have applied for, in order to protect your own and others’ health and safety. If you have any difficulties completing this form, or wish to discuss any issues in a confidential setting, please contact the Occupational Health Department for advice.

Please read this form carefully and answer all the questions before returning by email to the Occupational Health Department – [email protected]. This form and its contents will remain confidential to Occupational Health staff. Failure to disclose information or a false declaration may render the individual liable to summary dismissal. There is no need to send a hard copy in the post.

Post Applied for Full/part time/Bank hours per week Bank Department East Sussex Healthcare Trust Employee Hospital/Location

Section 1 Surname: Title Forenames: Date of birth Address: Post Code Contact No (day) Mobile No. E:mail address GP Dr Address Tel No of GP Brief details of present and previous employment or training

Have you ever worked for or trained in the NHS before? YES NO If YES please give details

From: To: Where: Any other surname by which you have been known?

038d9acd50f60e2a93ab215b3f6a4295.doc 1 Click the ‘mouse’ on the box to indicate YES or NO The job involves & there is YES NO YES NO potential for exposure to: Manual handling tasks Solvents Patient handling Human tissue/fluids Driving Risk of eye injury Work at height Chemicals Shift work/night work Gluteraldehyde VDU operation Cytotoxic drugs Clinical waste handling Radiation Food handling Latex gloves Work with respiratory sensitiser Fumes Excessive dust Lone worker Excessive noise Confined spaces Excessive heat OTHER PMVA

Section 2 (Tuberculosis (TB Questionnaire) What is your country of origin? Have you recently worked or Yes No visited for a long period of time a country with a high TB rate as defined by the WHO? If so, which country and date of visit? Have you ever been treated for Yes No TB? Previous BCG: Yes No Scar: Yes No Approximate year: Skin test date: Result: Please tick if any of the below apply: Loss of appetite and weight loss Persistent cough Coughing up blood or blood stained sputum Unusually tired Have a fever, most often at night that can result in heavy night sweats Family history of TB

038d9acd50f60e2a93ab215b3f6a4295.doc 2 Section 3 (Vaccination History) Have you ever had any of the following vaccinations? Please indicate YES/NO or not known. If you know the date or approximate date please indicate. Immunisation Yes No Not known Dates if known

Hepatitis B primary course Dose 1 Dose 2 Dose 3 Dose 4 accelerated course Hepatitis B repeat course if needed Hepatitis B Booster Known non-responder to Hepatitis B vaccine Measles (single doses)

Rubella (German measles) (single doses) Measles, Mumps and Rubella (MMR) Dose 1 Dose 2 Varicella (chicken pox) Dose 1 Dose 2 Hepatitis A Typhoid Polio Tetanus Diphtheria Diphtheria, Tetanus & Polio combined (DTP) If you have a record of your BCG (Tuberculosis) vaccination or TB skin test please supply or your start date may be delayed.

Have you had any of the following Yes No Not Dates illnesses? known (a) varicella (chicken pox)? (b) shingles? (c) rubella (German measles)? (d) measles? (e) mumps?

Section 4

If your job involves any of the following: Direct patient care, House-keeping/cleaning/disposal of rubbish or clinical waste, Laboratory work, or any other work that may require you to wear latex (rubber) gloves please answer the following questions.

(Natural Rubber Latex is found in many products in the healthcare setting. For example, gloves- examination and surgical, elastic bandages, ambu bags, adhesive tape etc. It is also found in the home. For example, household work gloves, condoms, balloons etc.

Medical history

Do you have a sensitivity to any latex products? Yes No 038d9acd50f60e2a93ab215b3f6a4295.doc 3 If Yes: describe the reaction What caused the reaction? Do you have a personal or family history of eczema, Yes No asthma or hay fever?

Do you have any allergic reaction if you eat any of the following: Banana Avocado Kiwi Fruit Chestnuts other nuts any other foods Please specify:

Do you have any of the following when exposed to latex? Dermatitis/eczema Urticaria/hives/nettle-rash Asthma Hay-fever Tight chest Coughing Sneezing Rhinitis/runny nose Itchy or runny eyes Anaphylactic reaction Have you had any local reaction or Yes No swelling/itching following medical/dental examination where latex gloves used? If Yes please give brief details

Does your current occupation involve Yes No exposure to latex?

Section 5 Have you suffered any of the following during Yes No Not Dates the last year? If yes, please include the date known and any treatment you had or are still having: Diarrhoea and / or vomiting Skin infections affecting hands, arms, face or head Sties, boils or septic fingers Discharge from eyes, ears, gums or mouth Recurring skin / ear problems

Recurring bowel disorder Skin problems caused by food or latex Breathing problems caused by food or latex Contact in the last 21 days with anyone at home or abroad who Yes No may have been suffering from typhoid or paratyphoid

IF YOU NEED TO GIVE ANY FURTHER INFORMATION PLEASE USE THIS SPACE

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NIGHT WORKERS HEALTH SCREENING

If you are required to work three hours or more between 10.00 pm and 7.00 am, as part or your normal work, you will be classified as a “Night Worker” under the “Working Time Regulations”. You will, therefore, be entitled to a voluntary health screening. If you would like to pursue this, please contact the Occupational Health Department on (01273 446056) or by e-mail: [email protected]

Section 6

CONSENT AND DECLARATION

I agree to attend a medical examination, if necessary, and will give my permission to the Occupational Health Department to request any information that may be required from my General or other Medical Practitioner. I understand that this information will be used to assess fitness to work in the applied post. I certify that I have answered all questions truthfully and that I am not aware of any medical reason that would prevent me from carrying out the duties required of me in the post for which I am applying.

I DECLARE THAT ALL OF THE ABOVE STATEMENTS AND INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE.

Name – Print

Signature

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 Date received – (Date stamp)

......

 Form received by:

name ...... signed ...... date

 Fit

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 Request further information ......

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1 We need further information relating to your health questionnaire. 2 Please arrange an appointment with the Nurse Adviser for pre-employment health interview/ vaccination check. Please bring the following to the appointment if you have: Documentary evidence of TB screening / BCG/ record of any immunisations received and blood test results 3 Please arrange an appointment with the Occupational Health Doctor 4 You are advised to have a routine Hepatitis B booster 5 Your form is returned herewith. Please complete where indicated and return in the envelope provided. 6 Please telephone the Occupational Health Department on the above number once you have a start date from Human Resources and book a routine vaccination check 7 Please provide UK lab report detailing your immunity to Varicella(chicken pox) Rubella(German Measles) Hepatitis B antibodies as indicated in bold 8 Please provide evidence of 2 MMR vaccines or a UK lab report detailing your immunity to Measles. Please provide documentary evidence of your BCG (TB) vaccination/scar or TB screening. If 9 you do not have this information please telephone the Occupational Health Department on the above number and arrange an appointment with the Practice Nurse or Nurse Advisor.. If classified Exposure Prone Procedure (EPP) Worker please provide an Identified 10 Validated Sample report of the following:

*a Your Hepatitis B immune status by way of a validated UK laboratory report *b Evidence of Hepatitis B surface Antigen (HBsAg) negative by way of a validated UK laboratory report *c Evidence of Hepatitis C antibody negative by way of a validated UK laboratory report *d Evidence of HIV status by way of a validated UK laboratory report *e Prospective employees designated as EPP workers should bring photographic identity i.e. passport or driving licence if attending for appointment in case of blood test.

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