PRIVATE AND CONFIDENTIAL

Section 1 - Resourcing Team to complete	
The Equality Act 2010 requires the Trust to make reasonable adjustments to jobs for reasons of disability. Any information provided on this form will be used to enable the Trust to support you in this role.	
JOB INFORMATION (To be completed by the Resourcing)	
JOB TITLE		
DEPARTMENT		DIVISION		
RESOURCING OFFICERS	TELEPHONE NO / EXTN	
MANAGER			
RESOURCING 			
Section 2 – Applicant to complete	
PERSONAL DETAILS (To be completed by Candidate)	
TITLE	Mr/Mrs/Miss/Ms/Dr/Rev/Other_____	DOB		
SURNAME		
FIRST NAME(S)		
ADDRESS		
		
TOWN/CITY		
POST CODE		
TELEPHONE		MOBILE		
EMAIL		
The Occupational Health Department aims to assist managers and staff in preventing work related ill health and promoting good health amongst Trust employees.                                                                   Please Tick	
Please respond to either question below as appropriate:

1.	“I am not aware of any health conditions or disability which might impair my ability to undertake effectively the duties of the position which I have been offered”.
OR
2.	“I do have a health condition or disability which might affect my work and which might require special adjustments to my work or at my place of work”

If you have ticked the second question you will be contacted by an OH professional who will discuss with you your support needs.	

	
		
Section 3 - For completion by Applicant 	YES	NO	
Have you been employed by University Hospital or the NHS previously?

If ‘yes’ what was the name of the employer?	

	
Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006)
Have you lived or worked continuously in the UK for the past 5 years?

Do you suffer from any of the following symptoms: 	

   Cough lasting more than 3 weeks 	

   Blood-stained sputum 	

   Fever/high temperature 	

   Unexplained weight loss 	

   Heavy sweating at night 	

Do you have any skin conditions e.g eczema, psoriasis?
        (UHCW Hand Decontamination Policy 2010)			

Have you ever been vaccinated or immunised against any of the following?  If YES please give details and  include documentary evidence if available.  If exact dates not known please give year.	

VACCINATION	RECEIVED	CHILDHOOD OR FIRST
COURSE DATES	OTHER DATES	COMMENTS	
Tuberculosis (BCG)	YES/NO				
Rubella (German Measles)	YES/NO				
Hepatitis B	YES/NO				
MMR (measles, mumps, rubella)	YES/NO				
Varicella Zoster (Chicken Pox)	YES/NO				

Have you ever had:		
Chicken Pox or Shingles (Please specify)	YES  / NO  /  DON’T KNOW	

*Exposure Prone Procedures Workers - have you had blood tests for any of the following? 
PLEASE PROVIDE A COPY	
NB:  Only UK accredited laboratory reports or a validated UK Occupational Health Service immunisation report / certificate will be accepted as evidence if the post involves *exposure prone procedures. Healthcare workers who perform EPPs have a legal duty to inform the Occupational Health team if they suspect or know that they are carriers of HIV, hepatitis B or hepatitis C.	
*Exposure prone procedures are those which carry a risk of occupational injury by exposure of the patients open tissues to the blood of the healthcare worker. Procedures include those where the workers gloved hand may be in contact with sharp instruments, needle tips and sharp tissues e.g. spicules of bones or teeth inside a patients open body cavity, wound or a confined anatomical space where the hands or fingertips may not be completely visible at all times	
INFECTION		DATE		
Hepatitis B Antigen	YES/NO		DETECTED / NOT DETECTED	
Hepatitis B antibody	YES/NO		IMMUNE  /  NON-IMMUNE  TITRE LEVEL IF KNOWN 	
Hepatitis C antibody	YES/NO		DETECTED / NOT DETECTED	
HIV Antibody	YES/NO		DETECTED / NOT DETECTED	
Rubella antibodies (German Measles)	YES/NO		DETECTED / NOT DETECTED	
Measles Antibody	YES/NO		DETECTED / NOT DETECTED	
Chicken Pox antibodies	YES/NO		DETECTED / NOT DETECTED	

Do you smoke tobacco?	YES / NO	
Would you like to be referred to the UHCW Stop Smoking Service? 	YES / NO	

I AGREE to attend Occupational Health Clinics, when requested, to discuss having any immunisations, tests and any other issues that arise relating to my ability to carry out my role. I give my CONSENT to Occupational Health consulting my GP, Consultant, any other Occupational Health Service or any other Health Services, and I authorise them to reply to enquiries, solely relating to any vaccinations, immunisations or immunity checks that I have undergone.	

SIGNED:	DATE:	

FULL NAME (Block capitals please):