<p> UCL HUMAN RESOURCES DIVISION OCCUPATIONAL HEALTH SERVICE</p><p>PRE-PLACEMENT HEALTH ASSESSMENT QUESTIONNAIRE</p><p>Incomplete details will delay processing of the form and advice on fitness for work.</p><p>To be completed by the APPLICANT. Surname Title Date of birth </p><p>Forenames Previous name </p><p>Address </p><p>Contact details - home - mobile </p><p>- work - email To be completed by the MANAGER. Job Title Full Time Part Time </p><p>Department </p><p>Location Start Date </p><p>The job involves work with:</p><p>Laboratory allergens or latex NHS / Patient contact</p><p>Microbiological work / human blood products Food handling</p><p>Regular overseas travel Regular night shifts</p><p>Group II vehicle driving duties</p><p>P lease provide applicant with appropriate supplementary health screening form to be returned attached.</p><p>Employing Manager’s details:</p><p>Name Signature Date </p><p>Tel Email </p><p>I enclose supplementary questionnaires for the following:</p><p>Driving Food handler</p><p>Work with laboratory allergens or latex Night Worker</p><p>NHS Honorary Contract/Direct Patient Manual handling Contact</p><p>Vaccination history Food handler  UCL Occupational Health Service will retain the completed health questionnaires. The information will be used to assess whether you have any medical impairment relevant to the proposed work and to guide UCL on any special requirements you may have during employment. Further assessment by the Occupational Health Service may be needed and you may be required, because of the nature of your work, to attend for regular health surveillance during employment. Advice regarding fitness for work will be given to your employing officer in general terms; detailed clinical information will not be revealed without your consent.  If further information is required from your GP or Specialist this will only be obtained with your written consent.  In signing this questionnaire you confirm that all information provided is true to the best of your knowledge. You also accept that in the event of being employed, if it is subsequently shown that medical information has not been disclosed by you, or has been misleading or false, then you could become liable to disciplinary proceedings that may include dismissal. When you have completed this form and the relevant supplementary questionnaire, please send it directly by post to: Occupational Health Service, University College London, Gower Street, London WC1E 6BT by email to: [email protected] or by fax to: +44 (0) 20 7209 0256</p><p>Please check that you have completed the relevant questionnaires and given all the information required. Please now complete the declaration below. Failure to do so may delay your application.</p><p>To be completed by the APPLICANT.</p><p>1. I declare that all the questionnaire responses are true to the best of my knowledge. 2. I understand and accept that I may be required to attend for an Occupational Health assessment or health surveillance. 3. I understand and accept that further medical information may be requested from my doctor if considered necessary and subject to the occupational health adviser obtaining my consent under the Access to Medical Reports Act 1988</p><p>Name (BLOCK CAPITALS): </p><p>Signature: Date:</p><p>FOR OFFICE USE ONLY</p><p>SATISFACTORY HEALTH SURVEILLANCE SCHEDULE PRE PLACEMENT ASSESSMENT IMMUNISATION ASSESSMENT SIGNATURE: DATE:</p>