Lane Fox REMEO Occupational Health New Starter Assessment Form

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This form must be completed by new starters at the Lane Fox REMEO Centre.

In the field marked “Department” below, please include details that state you are an employee at the Lane Fox REMEO Centre, so that we may process your form appropriately.

 

Answers to this questionnaire are confidential to the Occupational Health Department and will not be disclosed to anyone else without your permission. The purpose of the questionnaire is to identify the need for any adjustments/accommodations within the workplace and so it is important that you give full details of any health concerns/physical limitations in order that appropriate advice can be given to assist with your wellbeing at work. It will also identify any immunisation needs / baseline health surveillance required for your post.

You will be required to upload your proof of immunisations before submitting your form.

This health assessment form will be stored securely and will only be accessible to the Occupational Health Team.

Please complete each field as much as possible. If you do not know the information required, please leave blank.

If known
If known
Please select the site(s) where you will be based
Please select from the drop-down menu
This will be the name of the coordinator that has emailed or written to you

Personal details - to be completed by all staff

Please use the following format: dd-mm-yyyy

Previous employment in the last 5 years (please complete fully)

Please use the following format: dd-mm-yyyy
Please use the following format: dd-mm-yyyy

Please use the following format: dd-mm-yyyy
Please use the following format: dd-mm-yyyy

Please use the following format: dd-mm-yyyy
Please use the following format: dd-mm-yyyy

Please use the following format: dd-mm-yyyy
Please use the following format: dd-mm-yyyy

Section 1

Clinical diagnosis and management of Tuberculosis (TB) and measures for its prevention and control (NICE 2006)

Section 2

Please contact your previous OH provider / GP for information and/or proof of vaccination history and antibody response and send with your work health assessment – this will help avoid unnecessary delays in processing your health form.

If you have a scanned or digital copy of your vaccination history, you may upload this document at the end of the form.

EXPOSURE PRONE PROCEDURES

EPPs are defined as: “where there is a risk that an injury to the worker may result in the open tissues of a patient being exposed 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 a patients open body cavity, wound or confined anatomical space and where the hands or finger tips may not be completely visible at all times”

EPP staff include: All surgeons, all FY1 and FY2 doctors with a rotation into one of the EPP areas, dental nurses &doctors, theatre nurses &doctors midwives, ED doctors and nurses. If you are unsure about your EPP status, please contact the Occupational Health Team on 01737231631. All bank/agency staff nurses will be treated as EPP workers.

EPP staff who started before 2002 MUST provide documentary evidence of hepatitis B status only. Those who started after 2002 must provide hepatitis B and hepatitis C status. Those who started after 2007 must provide documentary evidence of hepatitis B, hepatitis C and HIV status. This is also required for staff undertaking EPPs for the first time. This must be an identified validated sample (IVS). Health clearance for EPP work cannot be given until these results have been received and processed by the OH Team. IF YOU HAVE PREVIOUS BLOOD RESULTS AND / OR DOCUMENTED EVIDENCE OF RELEVANT VACCINATIONS PLEASE SUPPLY A COPY WHEN YOU SUBMIT THIS FORM.

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. You will be asked to show formal photographic ID i.e. valid driver’s licence, passport or staff ID for this procedure. This is to comply with the Department of Health’s standard for Identified Validated samples (IVS).

Section 3

HEALTHCARE WORKERS WHO PERFORM EPPs HAVE A LEGAL DUTY TO INFORM OCCUPATIONAL HEALTH (IN CONFIDENCE) IF THEY SUSPECT OR KNOW THAT THEY ARE CARRIERS OF HIV, HEPATITIS B OR HEPATITIS C.

Section 4

If you have been confirmed as having any of these above conditions please provide evidence either from your G.P, Occupational Health or the department where the diagnosis has been made

Please Read

Depending on risk factors declared, applicants may be invited to attend Occupational Health for further skin assessment after they take on their post with the Trust.

Healthcare workers who later on develop skin problems during the course of their work are responsible to report their condition to Occupational Health.

Section 5

Please tick the box below to confirm you have read and understand the declaration below.

ALL NEW STAFF ARE INVITED TO DISCUSS WITH OCCUPATIONAL HEALTH ANY CONCERNS THEY MAY HAVE ABOUT THEIR HEALTH AND WORK

Please enter your full name to complete this form
If you have been unable to upload your immunisation record then please email it separately to ssx-tr.sashoccupationalhealth@nhs.net, clearly stating your full name and that your attached documents are immunisation details.

I have read and accept the terms & conditions.