Medical Questionnaire | Total Assist

CONFIDENTIAL

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Department

Name(Required)

First Middle Last

Date of Birth

DD slash MM slash YYYY

Email(Required)

Home Tel

Work Tel

Mobile

Home Address

Street Address Address Line 2 City County Poste Code

GP Address

Street Address Address Line 2 City County Poste Code

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.

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?(Required)

Yes

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?(Required)

Yes

Are you having, or waiting for treatment (including medication) or investigations at present? If your answer is yes, please provide further details of the condition, treatment and dates(Required)

Yes

Do you think you may need any adjustments or assistance to help you do the job?(Required)

Yes

Have you suffered from any of the following? *

methicillin resistant staphylococcus aureus (MRSA)?(Required)

Yes

clostridium difficile (C-Diff)?(Required)

Yes

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

Chicken Pox or Shingles

Have you ever had chicken pox or shingles?(Required)

Yes

If YES, when?(Required)

DD slash MM slash YYYY

BBV (Blood Borne Virus)

Have you ever come into contact with any BBV’s? Including Needle Stick Injuries?(Required)

Yes

Tuberculosis

Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006)

Have you lived continuously in the UK for the last year (Include Holidays/Vacations)(Required)

Yes

If you have answered NO to the above, please list all of the countries that you have livedin/visited over the last year, including holidays and vacations. This MUST include duration of stay and dates or this form will be rejected.(Required)

Have you had a BCG vaccination in relation to Tuberculosis?(Required)

Yes

If you answered yes please state when(Required)

DD slash MM slash YYYY

Tuberculosis Continued

Do you have any of the following?

A cough which has lasted for more than 3 weeks(Required)

Yes

Unexplained weight loss(Required)

Yes

Unexplained fever(Required)

Yes

Have you had tuberculosis (TB) or been in recent contact with open TB(Required)

Yes

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

Have you had any of the following immunisations?

Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)(Required)

Yes

Triple vaccination as a child (Diptheria / Tetanus / Whooping cough) Date(Required)

DD slash MM slash YYYY

Polio(Required)

Yes

Polio Date(Required)

DD slash MM slash YYYY

Tetanus(Required)

Yes

Tetanus Date(Required)

DD slash MM slash YYYY

Hepatitis B(Required)

Yes

Hepatitis B - Course (1) Date(Required)

DD slash MM slash YYYY

Hepatitis B - Booster Date(Required)

DD slash MM slash YYYY

Hepatitis B - Course (2) Date(Required)

DD slash MM slash YYYY

Course 2 Booster(Required)

DD slash MM slash YYYY

Hepatitis B - Course (3) Date(Required)

DD slash MM slash YYYY

Course 3 Booster(Required)

DD slash MM slash YYYY

Proof of Immunity (Please send the following)

Drop files here or

Max. file size: 32 MB, Max. files: 15.

Varicella - We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare). Tuberculosis - We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare) Rubella, Measles & Mumps - Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella and Measles Hepatitis B - You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above Proof of Immunity (Please send the following) EPP Candidates Only Hepatitis B Surface Antigen - Evidence of a negative Surface Antigen Test Report must be an identified validated sample. (IVS) Hepatitis C - Evidence of a negative antibody test Report must be an identified validated sample. (IVS) HIV - Evidence of a negative antibody test Report must be an identified validated sample. (IVS)

Will your role involve Exposure Prone Procedures ?(Required)

Yes

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 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’.

Do you consent to this questionnaire and your immunisation reports being assessed by an Occupational Health Advisor for the purpose of providing a Fitness to Work Certificate?(Required)

Yes

Do you consent to our Occupational Health Advisors speaking with you regarding any declaration you may have made relating to your medical history?(Required)

Yes

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?(Required)

Yes

Declaration

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(Required)

First Last

Date(Required)

DD slash MM slash YYYY