PRE PLACEMENT
Screening and Immune Status Questionnaire
EMPLOYEES WITH DIRECT PATIENT
CONTACT AND LABORATORY STAFF
PERSONAL DETAILS:
Please ensure all details are completed.
Surname:
……………………………………..
First Name(s): ……………………………………………….
DOB:
.....................................................
Gender:
Position Offered:
.....................................................
Department:
Managers Name:
.....................................................
Hospital/Location: …………………………………………
Start Date:
.....................................................
Cost Code:
Home Phone #:
.....................................................
Mobile Phone #: .............................................................
.............................................................
.............................................................
Email:
......................................................................................................................................................... Have you
previously worked at Canterbury or W est Coast District Health Boards (DHB)
Y/ N
TUBERCULOSIS SYMPTOM QUESTIONNAIRE:
Please answer all questions by putting a tick in the appropriate box (Yes or No).
If you tick yes please provide more details.
Yes
No
Details
Have you lived or worked outside New Zealand in
the last five (5) years?
Have you had tuberculosis (TB) in the past?
If YES when and where did you have treatment?
Have you been in close contact with anyone who has
had TB in the last five (5) years?
Have you had in the last five (5) years:
 A persistent or recurring cough lasting for
more than three (3) weeks?
 Have you been coughing up blood?
 Excessive night sweating?
 Excessive unexplained weight loss?
 Persistent high fever?
If coming to New Zealand from a high risk country OR if you will be working in the Labs please
provide blood test result for:
 Tuberculosis (Quantiferon TB Gold) / Heaf test / Mantoux
Ref:
Authorised by: Occupational Health
Page 1 of 2
Date of issue: 07-Jun-2013
IMMUNITY STATUS:
EMPLOYEES WITH DIRECT CONTACT
(Nurse, Doctor, Physiotherapist, Orderly, Social Worker…)
Screening and Immunisation History:
Had the disease varicella (chickenpox)?
 Yes
 No
Received the MMR vaccination:
 Yes
 No
Approx date: ...........................................
Received the Pertussis Combined vaccination:
 Yes
 No
Approx date: ...........................................
LABORATORY STAFF
Screening and Immunisation History:
Had the disease varicella (chickenpox)?
 Yes
 No
Received the MMR vaccination:
 Yes
 No
Approx date: ...........................................
Tuberculosis: Mantoux/Heaf test/TB blood test
 Yes
 No
Approx date: ...........................................
Chest x-ray
 Yes
 No
(Following a positive Mantoux/Heaf test/TB blood test)
Approx date: ...........................................
The DHB requires you to be screened before commencing work to establish your immunity against certain
infectious diseases.
If this screening has been undertaken in other employment/university/college you will not need it
repeated, but we do need copies of previous laboratory test results as outlined below.
If your laboratory test results show you have no immunity to certain infectious diseases we can offer you
the appropriate vaccination at no charge on commencement of employment.
All applicants MUST provide laboratory test results for the following diseases prior to commencing
employment with the Canterbury and West Coast DHB:
 Hepatitis B Immune Status
-
If you have had past vaccinations you require Hepatitis B surface antibody test
If you have NOT had vaccination you require Hepatitis B surface antigen test & surface antibody
 Mumps Immune Status
 Rubella Immune Status
 Measles Immune Status
 Varicella (chickenpox) Immune Status (if not had the disease)
PLEASE RETURN THIS QUESTIONNAIRE AND ACCOMPANYING LABORATORY TEST RESULTS
TO:
Occupational Health
Level 4, Heathcote Building, The Princess Margaret Hospital
Cashmere Road, PO Box 800, CHRISTCHURCH
STATEMENT OF AGREEMENT
I consent to being contacted by Occupational Health for follow up regarding information provided on this questionnaire.
I consent to my information being held by Occupational Health for ongoing monitoring and care.
I understand the collection, use and storage of this information by Occupational Health will at all times comply with the guidelines
for the Privacy Act 1993 and the Health Information Privacy Code 1994. I declare that to the best of my knowledge the information
above is entirely true and correct and I understand that if any false information is given or relevant material suppr essed or not
supplied I may not be employed or if employed subject to appropriate disciplinary action, which may include dismissal.
Signature:
Ref:
.......................................................................
Authorised by: Occupational Health
Date:
...................................................
Page 2 of 2
Date of issue: 07-Jun-2013