CONFIDENTAL
RECRUITMENT BUREAU/ BANK OFFICE (delete as applicable) Occupational Health
Chase Farm Hospital
CLEARANCE TO ___________________________________________ The Ridgeway
Enfield
DATE ___________________________________________ Middlesex
EN2 8JL
CANDIDATES SHOULD NOT TERMINATE THEIR PRESENT 020 8375 1137
EMPLOYMENT BEFORE BEING INFORMED OF HEALTH CLEARANCE. FAX 020 8375 1047
EMAIL Ohealth@[Link]
Enfield Primary Care Trust
PRE-EMPLOYMENT HEALTH QUESTIONNAIRE
SURNAME MAIDEN NAME NEXT OF KIN
(if applicable) Name
Relationship
Dr/Mr/Mrs/Miss/Ms Tel
FIRST NAMES NATIONAL INSURANCE No
DATE OF BIRTH POST APPLIED FOR:
COUNTRY OF BIRTH DEPT _______________________________
SITE ________________________________
HOME ADDRESS
Does the post involve night work? YES NO
If YES, is it permanent? YES NO
TEL Home or Bank shifts? YES NO
Work
Mobile Expected date of commencement:
FAMILY DOCTOR Have you previously worked for this organization?
YES NO
Name
Address If YES, when did you leave?
Are you aware if the post applied for will involve any of the following? (Tick all that apply)
Possible exposure to blood or other substances Possible exposure to plaster dust
of human origin
Possible exposure to cytotoxic drugs
Handling patients
Possible exposure to chemicals
Handling food
Possible exposure to ionizing radiation
Possible exposure to methylmethacrylate
Possible exposure to anaesthetic gases
Driving
Possible exposure to noise
Are you allergic/sensitive to any foods or substances?
If YES, please give details YES NO
Are you allergic/sensitive to any natural rubber products e.g. gloves
If YES, please give details YES NO
Have you visited or arrived from any country other then USA/Canada/
Australia/New Zealand or EEC countries within the past year? YES NO
PREVIOUS WORKING HISTORY
To enable us to organize your occupational health care, please list all jobs you have had within the past 5 (FIVE) years. Please
include information about any special hazards or health risks to which you were exposed.
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FROM TO JOB DESCRIPTION/SPECIALITY HAZARD/HEALTH RISK
HAVE YOU HAD ANY OF THE FOLLOWING?
Please answer YES or NO, giving details and dates. If in doubt, please answer DON’T KNOW.
1. Skin conditions (including persistent spots or dermatitis)? _______________________________________________
2. Discharge or infection of the ears or defects of hearing? ________________________________________________
3. Asthma or hay fever, any allergic conditions and sensitivity to antibiotics or other medicines?
_____________________________________________________________________________________________
4. Recurrent sore throats? __________________________________________________________________________
5. Chest problems (i.e. persistent cough or infections)? ___________________________________________________
6. Tuberculosis? _________________________________________________________________________________
7. Heart problems? _______________________________________________________________________________
8. High blood pressure? ____________________________________________________________________________
9. Severe headaches (including migraine)? ____________________________________________________________
10. Blackouts (including fits and epilepsy)? ______________________________________________________________
11. Mental illness (including depression, nervous breakdown or eating disorders)? If YES, give details and treatment.
_____________________________________________________________________________________________
12. Neck or back problems? _________________________________________________________________________
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13. Bending or lifting problems? ______________________________________________________________________
14. Rheumatism, arthritis or painful joints? ______________________________________________________________
15. Varicose veins or foot problems? __________________________________________________________________
16. Stomach problems? _____________________________________________________________________________
17. Kidney or bladder problems? ______________________________________________________________________
18. Eye conditions (including injuries or defects of vision)? _________________________________________________
19. Diabetes? _____________________________________________________________________________________
20. Blood disorders, sickle cell, jaundice or liver problems? _________________________________________________
21. Any conditions requiring attendance at hospital (including operations and injuries)?
_____________________________________________________________________________________________
22. Any absence from work, college or school due to ill health during the past 2 years? If YES, please give details and state
number of days.
_____________________________________________________________________________________________
23. Do you consider yourself to have a disability? If YES, give details.
_____________________________________________________________________________________________
24. Do you/have you required any modification or additional equipment in your workplace to enable you to do your job? If YES,
give details.
_____________________________________________________________________________________________
25. Are you at present having any form of treatment from a doctor? If YES, give details.
_____________________________________________________________________________________________
26. Do you smoke? If YES, please state number per day. __________________________________________________
27. Would you consider that you have or have had a drink problem? __________________________________________
28. What is your weekly intake of alcohol? ______________________________________________________________
29. Height? __________________________ Weight? ___________________________ Does it remain steady? Yes/No
30. Do you have any medical conditions not listed on this form? ______________________________________________
If YES, give details
______________________________________________________________________________________________
FEMALE CANDIDATES ONLY This information is required to ensure you will not be exposed to any substances/
hazards which may be harmful to your unborn baby
Please state if you know or suspect you may be pregnant ________________________________________________
ALL CANDIDATES Have you had?
Chicken pox YES NO German Measles YES NO
Mumps YES NO Measles YES NO
VACCINATION HISTORY ANTIBODY TEST
HEPATITIS B course dates 1.____________________________
DATE ______________________
2.____________________________
RESULT
3.____________________________ ______________________
DATE OF BOOSTERS 1.____________________________
NOT VACCINATED (tick box if appropriate)
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HAVE YOU HAD THE FOLLOWING TESTS OR VACCINATIONS?
Please answer YES or NO, giving details and dates. If in doubt, please answer DON’T KNOW.
B.C.G. Yes/No DATE ________________ Heaf/Mantoux Yes/No DATE
________________
Measles/Mumps/Rubella (MMR) Yes/No DATE ________________ Measles Yes/No DATE
________________
Polio Yes/No DATE of COURSE ________________ BOOSTERS ________________
Rubella (German Measles) Yes/No DATE ________________
Rubella Antibody Test Yes/No DATE ________________
Tetanus Yes/No DATE of COURSE ________________ BOOSTERS ________________
Varicella (Chicken Pox) Antibody Test Yes/No DATE ________________
Triple vaccine as a child (Diptheria/Tetanus/Whooping cough) Yes/No DATE ________________
EXPOSURE PRONE PROCEDURES (EPPs)
If your job involves EPPs, (see attached list) please provide VALIDATED documentary evidence of the following:
HEPATITIS B - either a current satisfactory immunity status (antibody levels >100) or non-infectivity status (negative surface antigen
less than 6 months old).
HEPATITIS C - either a current negative antibody status or a negative RNA (less than 6 months old).
CLEARANCE TO COMMENCE WORK WILL NOT BE GIVEN UNTIL
THIS INFORMATION IS RECEIVED BY OCCUPATIONAL HEALTH.
I declare I have answered the questions on this form honestly and fully and I am not aware of any other physical or
mental disability that will or may affect my working capacity before retiring age. I am aware that false or incomplete
statements may affect my appointment of future employment. The Trust actively implements the Disability
Discrimination Act (1995).
SIGNATURE ____________________________________ DATE ____________________________________
Please ensure you have read, completed and signed both this page, and page 7.
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OFFICE USE ONLY
To Be Completed By Occupational Health
HEIGHT WEIGHT URINE B/P PULSE
VISION WITHOUT GLASSES WITH GLASSES (OR CONTACT LENSES)
Distance R.6/ L.6/ R.6/ L.6/
Near R. L R. L.
KEYSTONE Middle R. L. R. L.
Refer for further assessment? Yes/No Colour Vision ____________________________
RECOMMENDED VACCINATION PROGRAMME
Sharps Policy YES NO
Polio Course/Booster
Accident Policy
Tetanus Course/Booster
NURSE’S EXAMINATION Heaf/Mantoux
Ears ____________________________________ B.C.G.
Teeth ____________________________________ Rubella Vaccine
Skin ____________________________________ Rubella Titre
COMMENTS/ADVICE GIVEN (specify) Varicella Titre
Hepatitis B Course
Hepatitis B Booster
Hepatitis B Titre
PAPER SCREENING
YES NO NOT ENCLOSED N/A
Satisfactory evidence of Hepatitis B immunity
Satisfactory evidence of Hepatitis C non-infectivity
Nothing declared to indicate unsuitability for employment
Request applicant to contact OH
OH will contact applicant
Correspondence with GP/Specialist
Referred to OH Physician
SIGNATURE ____________________________________ DATE ____________________________________
FIT FOR EMPLOYMENT
SIGNATURE ____________________________________ DATE ____________________________________
CLEARANCE SENT TO _______________________________________________________________________________
BASELINE SCREENING
FIT FOR EMPLOYMENT
SIGNATURE ____________________________________ DATE ____________________________________
CLEARANCE SENT TO _______________________________________________________________________________
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DEPARTMENT OF OCCUPATIONAL HEALTH
SPECIAL GUIDANCE FOR HEALTHCARE WORKERS INVOLVED IN 'EXPOSURE PRONE PROCEDURES
(EPP's)
DEFINITION OF EPP'S
"Exposure prone procedures are those where there is risk that injury to the worker may result in the exposure of the patient's open
tissue to the blood of the worker. These procedures include those where the worker's gloved hands may be in contact with sharp
instruments, needle tips and sharp tissues (spicules of bone or teeth) inside the patient's open body cavity, wound or confined
anatomical space where the hands or fingertips may not be completely visible at all times". Expert Advisory Group on Hepatitis B -
August 1993.
IF YOU ARE INFECTED OR CONSIDER YOURSELF TO BE A CARRIER OF HEPATITIS B/C OR THINK
YOU MAY HAVE BEEN INFECTED WITH HIV, YOU HAVE AN ETHICAL DUTY TO INFORM
OCCUPATIONAL HEALTH.
EXAMPLE OF EMPLOYEES PERFORMING EPP’S
MEDICAL STAFF
All Surgeons, Obstetricians and Gynaecologists
Accident and Emergency Doctors
Cardiologists performing cardiac catheterisation or angiography
Dentists
All Bank Doctors/Locum Doctors/Clinical Assistants if working in the above specialities
NURSING STAFF
Theatre/Day Surgery Staff involved in ‘scrub procedures’ i.e. Nurses, ODA’s/ODP’s
Accident and Emergency Nurses
Midwives and Midwifery students
Dental nurses/dental students (certain tasks)
Hepatitis B carriers who are ‘e’ antigen positive or ‘e’ negative with a viral load, which exceeds 103 genome equivalents per ml, are not
permitted to perform EPP’s. (HSC2000/020)
Health Care Workers who are Hepatitis C virus RNA positive are not permitted to perform EPP’s (HSC2002/010)
HIV infected workers are not permitted to perform EPP’s. HSG(94)16
HEPATITIS B
Any person applying for one of the above posts MUST provide documented evidence of either a current satisfactory immunity status
(antibody levels >100) OR non-infectivity status (negative surface antigen less than six months old).
HEPATITIS C
Any person applying for one of the above posts MUST provide documented evidence of either a current negative antibody status OR a
negative RNA (less than six months old).
CLEARANCE TO COMMENCE WORK WILL NOT BE GIVEN UNTIL THIS
INFORMATION IS RECEIVED BY OCCUPATIONAL HEALTH.
Venepuncture, the giving of injections and the setting up of intravenous lines is not considered to be ‘exposure prone procedures’.
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TUBERCULOSIS (TB)
Please return this completed form with your health questionnaire.
FAILURE TO DO SO MAY DELAY COMMENCEMENT OF YOUR EMPLOYMENT
Due to an increase in reported cases of TB in the UK, it is necessary to ask you the following questions.
1. Is this your first post within the NHS?
YES/NO (delete as appropriate)
2. Have you come to the UK from any other country within the past 5 years?
YES/NO (delete as appropriate)
If YES please state which country/countries
______________________________________________________________________
Have you travelled to any country outside the UK recently and stayed longer than 2 months?
YES/NO (delete as appropriate)
If YES please state which country/countries
______________________________________________________________________
3. Have you recently been in contact with anyone suspected or known to have tuberculosis?
YES/NO (delete as appropriate)
4. Have you any symptoms compatible with tuberculosis i.e. persistent cough/fever and/or weight loss/ heavy sweating at
night?
YES/NO (delete as appropriate)
Name (PRINT) ________________________________________________________________
Signature ________________________________________________________________
Date ________________________________________________________________
