WORK HEALTH ASSESSMENT
CONSENT AND DECLARATION
TO BE COMPLETED BY THE APPLICANT FOLLOWING OFFER OF EMPLOYMENT
Your answers to this questionnaire will be confidential to the Occupational Health team and will not be given
to anyone else without your written permission.
The purpose of the questionnaire is to see whether you have any health problems that could affect your ability
to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may
recommend adjustments or assistance as a result of this assessment to enable you to do the job.
Our aim is to promote and maintain the health of all people at work. Before health clearance is given for
employment you may be contacted by Occupational Health and may need to be seen by an Occupational
Health advisor or physician.
I agree to attend a medical examination if necessary. I consent to the outcome of this paper screening
regarding my fitness for the post being communicated to Medical HR (specific health problems will remain
confidential to the Occupational Health Department).
Full Name:
Date:
Start Date:
Personal Details
(Medical HR use only)
Please mark with an X as appropriate.
Surname:
Title:
First Names:
Male:
Gender:
Any other
surname(s) used:
Female:
Date of Birth:
Address:
Post Code:
Home Telephone
Number:
Email Address:
Mobile Telephone
Number:
St Richard’s Hospital:
Job Title (new):
Department (new):
Location:
Recruiting Manager’s
Name:
Worthing Hospital:
Southlands Hospital:
Have you ever been employed by the NHS before?
Yes:
No:
Are you currently employed by Western Sussex Hospitals NHS Foundation Trust?
Yes:
No:
Occupational Health Service provided by Portsmouth Hospitals NHS Trust
Please mark with an X as appropriate.
1.
Do you have any illness/impairment/disability (physical or psychological)
which may affect your work?
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
If yes, please
give details:
2.
Have you ever had any illness/impairment/disability which may have been
caused or made worse by your work?
If yes, please
give details:
3.
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.
If yes, please
give details:
4.
Do you think you may need any adjustments or assistance to help you to
do the job?
If yes, please
give details:
To be completed by THOSE STAFF whose job may involve NIGHT WORK
1.
Have you ever worked nights before?
Yes:
No:
2.
If yes, during this time did you ever suffer from any health problems
associated with working at night e.g. difficult blood sugar control if
diabetic, respiratory symptoms if asthmatic, night-time seizures with
epilepsy, severe sleep disturbance?
Yes:
No:
3.
Do you consider yourself fit to undertake night work?
Yes:
No:
2
To be completed by FOOD HANDLERS e.g. all catering staff, nurses, housekeepers, therapy staff etc
involved in the handling or preparation of food
1.
Have you ever had, or are you now known to be a carrier of typhoid or
paratyphoid?
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
If yes, please
give details:
2.
Are you a carrier of any other food borne disease or parasitic infection?
If yes, please
give details:
3.
In the last 21 days, have you been in contact with anyone, at home or
abroad who may have been suffering from typhoid or paratyphoid fever?
If yes, please
give details:
4.
At present are you suffering from:

Recurrent or persistent skin infections?
If yes, please
give details:

Recurrent attacks of diarrhoea?
If yes, please
give details:
5.
Do you suffer from:

Chronic infections of the ear, eyes, nose, throat or gums?
If yes, please
give details:

Dental problems?
If yes, please
give details:
3
TO BE COMPLETED BY ALL APPLICANTS
LATEX ALLERGY
1.
Have you been diagnosed as suffering from a latex (natural rubber)
allergy?
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
If yes, please
give details:
2.
Have you ever had a reaction following contact with products containing
latex?
If yes, please
give details:
3.
Have you every had a reaction after eating the following foods: Banana,
Avocado, Kiwi, Chestnut, Potato, Mango, Tomato
If yes, please
give details:
4.
Do you have a history of contact dermatitis when wearing gloves?
If yes, please
give details:
5.
Have you ever had a severe allergic reaction in the presence of latex (e.g.
wheezing, facial swelling, collapse)?
If yes, please
give details:
4
Failure to provide the following information will delay health clearance for work
Do you have a history of Chicken Pox?
Yes:
Don’t Know:
No:
In which country were you born?
Tuberculosis (TB)
Have you lived / worked abroad in the last five years?
Yes:
No:
Have you had any contact with TB?
Yes:
No:
Have you got a persistent cough?
Yes:
No:
Do you suffer from night sweats?
Yes:
No:
Have you had unexplained weight loss?
Yes:
No:
Have you had a BCG vaccination?
Yes:
No:
Do you have a scar?
Yes:
No:
Have you had a Mantoux test?
Yes:
No:
If yes:
Date:
Result:
Vaccination History/Blood Test Results
You must check with your GP/previous Occupational Health Department for dates and results before
completing this section.
Please supply copies of vaccination history/blood test results for the following:
Tetanus
Poliomyelitis
Typhoid
Chicken Pox
MMR
Measles
Mumps
Rubella
Hepatitis A
Hepatitis B
If you have previous blood results and/or documented evidence of relevant vaccinations please supply a copy
when you submit this form.
5
Exposure Prone Procedures (EPP)
Exposure Prone Procedures (EPP) are those procedures where the worker’s gloved hands may be in contact
with sharp instruments, needle tips or sharp tissue (e.g. spicules of bone or teeth) inside a patient’s open body
cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all
times.
EPP staff include: All surgeons (including FY1 and FY2 doctors with a rotation into one of the EPP areas),
dental staff, theatre staff and midwives.
As part of the Western Sussex Hospitals NHS Trust pre-employment screening policy it is necessary for you
to provide documentary evidence of the below results. If this is not available before commencement of post
you will be required to have bloods taken for the necessary tests and should contact the Occupational Health
Department as soon as possible on the telephone numbers below.
EPP staff MUST provide documentary evidence of Hepatitis B, Hepatitis C and HIV status.
This must be an identified validated sample (IVS) taken in the UK.
If results are not available you will be tested in this department and health clearance for EPP work will be
delayed until these results are processed.
Health clearance for EPP work cannot be given until these results are available
Date of HIV antibody test
Copy of result attached:
Date of Hepatitis B surface antigen test
Copy of result attached:
Date of Hepatitis C antibody test
Copy of result attached:
Please email this completed form to [email protected]
Please note in the email subject line for which is applicable for your application:
Work Health Assessment – St Richard’s Hospital
or
Work Health Assessment – Worthing/Southlands Hospital
Alternatively, please return this completed form to the hospital you will be working at:
St Richard’s Hospital
Worthing and Southlands Hospitals
Occupational Health
Western Sussex Hospitals NHS Foundation Trust
St Richard’s Hospital
Spitalfield Lane
Chichester
West Sussex
PO19 6SE
Occupational Health
Western Sussex Hospitals NHS Foundation Trust
Worthing Hospital
Lyndhurst Road
Worthing
West Sussex
BN11 2DH
Direct Line
Internal Ext
Fax
Direct Line
Internal Ext
(01243) 831478
2403
(01243) 831479
6
(01903) 285276
5276