Step 1 of 5 - Personal information 0% Personal informationTitlePlease select a titleMrMrsMissMsDrName First Last Date of birth DD MM YYYY Home phoneWork phoneMobile phoneHome addressGP address Medical historyDo you have any illness/impairment/disability (physical or psychological) which may affect your work?YesNoHave you ever had any illness/impairment/disability which may have been caused or made worse by your work?YesNoAre you having, or waiting for treatment (including medication) or investigations at present?YesNoDo you think you may need any adjustments or assistance to help you to do the job?YesNoHave you suffered from methicillin resistant staphylococcus aureus (MRSA)?YesNoWhen did you suffer from MRSA?* DD MM YYYY Have you suffered from clostridium difficile (C-Diff)?YesNoWhen did you suffer from C-Diff?* DD MM YYYY 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) Have you ever had chicken pox or shingles?YesNoWhat date did you have chicken pox or shingles?* DD MM YYYY Have you ever come into contact with any Blood Borne Virus (BBVs)? Including Needle Stick Injuries?YesNo 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?YesNoAs 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?YesNoAs you've answered YES to the previous question, please state when you had you BCG vaccination DD MM YYYY Do you have any of the following Tuberculosis symptoms? A cough which has lasted for more than 3 weeksYesNoUnexplained weight lossYesNoUnexplained feverYesNoHave you had tuberculosis (TB) or been in recent contact with open TB?YesNoAs you have answered YES to one of the above TB questions, please provide additional information here.* Immunisation historyHave you had any of the following immunisations?Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)YesNoWhen did you have the triple vaccination? DD MM YYYY PolioYesNoWhen did you have the Polio vaccination? DD MM YYYY TetanusYesNoWhen did you have the Tetanus vaccination? DD MM YYYY Hepatitis BYesNoAs you have answered 'yes' to the Heaptitis B question, please give dates belowCourse 1 DD MM YYYY Course 2 DD MM YYYY Course 3 DD MM YYYY Booster 1 DD MM YYYY Booster 2 DD MM YYYY Booster 3 DD MM YYYY Proof of immunity (please send the following)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 immunityWe require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella and MeaslesYou must provide a copy of the most recent pathology report showing titre levels of 100lu/l or aboveProof of immunity (please send the following) - EPP candidates onlyEvidence of Hepatitis B Surface Antigen Test (Inc. ‘e’ antigen and DNA viral loads if applicable. Report must be an identified validated sample. (IVS)Evidence of a Hepatitis C antibody test (Inc. Hepatitis C RNA/PCR if applicable). Reports must be an identified validated sample. (IVS)Evidence of a HIV I and II antibody test (Inc. DNA viral loads if applicable). Reports must be an identified validated sample. (IVS)To upload any of the supporting immunisation documentation, use this file upload facility. Drop files here or Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, txt, rtf. Will your role involve Exposure Prone Procedures?YesNoThe 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, 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./p>Recommendations I understand that following this assessment, recommendations may be provided to assist my health at work;I give consent for the Healthier Business UK Ltd to make recommendations and for my employer/agency to provide these recommendations to my placementYesI would like to see a written copy of any recommendations Healthier Business UK Ltd may make before my employer/agency provide them to my placementYesI 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.YesI declare that the answers to the above questions are true and complete to the best of my knowledge and belief.YesSignatureSignaturePlease add your initials to confirm that everything submitted in this form is accurateEmailThis field is for validation purposes and should be left unchanged.
