Step 1 of 4 - Personal information 0% Before health clearance is given for employment you may be contacted by Healthier Business UK 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. Your record will be held on file for the purposes of processing your request and for no longer than is necessary. Your records may also 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 informationTitle*Please select a titleMrMrsMissMsDrName* First Last Email* Date of birth* Day Month Year Home phone*Work phone*Mobile phone*Home address*GP address* Medical historyHave you ever come into contact with any Blood Borne Virus (BBVs) since you were initially screened by Occupational Health including Needle Stick Injuries?* Yes No Have you suffered from methicillin resistant staphylococcus aureus (MRSA)* Yes No When did you suffer from MRSA?* Day Month Year Have you suffered from clostridium difficile (C-Diff)?* Yes No When did you suffer from C-Diff?* Day Month Year As you have answered yes to one or more of the Medical History questions, you must provide further details in this additional information section. Failure to do so will result in the form being returned/rejected.*If you have answered 'yes' to any questions above, please provide additional information including dates, treatment and details of condition) TuberculosisClinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2016)Have you lived outside the UK or had an extended holiday outside the UK in the last year?* Yes No As you 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.*Have you had a BCG vaccination in relation to Tuberculosis?* Yes No As you've answered YES to the previous question, please state when you had you BCG vaccination* Day Month Year Do you have any of the following Tuberculosis symptoms? A cough which has lasted for more than 3 weeks* Yes No Unexplained weight loss* Yes No Unexplained fever* Yes No Have you had tuberculosis (TB) or been in recent contact with open TB?* Yes No As you have answered YES to one of the above TB questions, please provide additional information here.* The General Data Protection Regulation (GDPR) (EU) 2016/679 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 any supporting documentation, being assessed by an Occupational Health Advisor 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 your ability to carry out your prospective role?* Yes No I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.* Yes I will inform my employment agency 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.* Yes Changes to your healthPlease ensure to tick one option only in this sectionI confirm that I have reviewed my health questionnaire and there has been no changes to my health in the past year.* Yes I confirm that I have reviewed my health questionnaire and I have listed the changes here, in this form. Yes SignatureSignature*Please add your initials to confirm that everything submitted in this form is accurate* EmailThis field is for validation purposes and should be left unchanged.
