Professional Documents
Culture Documents
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Does the post involve night work? YES NO
Are you aware if the post applied for will involve any of the following? (Tick all that apply)
Have you visited or arrived from any country other then USA/Canada/
Australia/New Zealand or EEC countries within the past year? YES NO
3. Asthma or hay fever, any allergic conditions and sensitivity to antibiotics or other medicines?
_____________________________________________________________________________________________
6. Tuberculosis? _________________________________________________________________________________
11. Mental illness (including depression, nervous breakdown or eating disorders)? If YES, give details and treatment.
_____________________________________________________________________________________________
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13. Bending or lifting 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.
_____________________________________________________________________________________________
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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? __________________________________________
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
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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.
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).
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
Hepatitis B Course
Hepatitis B Booster
Hepatitis B Titre
PAPER SCREENING
YES NO NOT ENCLOSED N/A
Satisfactory evidence of Hepatitis B immunity
Referred to OH Physician
BASELINE SCREENING
FIT FOR EMPLOYMENT
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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.
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)
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).
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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.
2. Have you come to the UK from any other country within the past 5 years?
______________________________________________________________________
Have you travelled to any country outside the UK recently and stayed longer than 2 months?
______________________________________________________________________
3. Have you recently been in contact with anyone suspected or known to have tuberculosis?
4. Have you any symptoms compatible with tuberculosis i.e. persistent cough/fever and/or weight loss/ heavy sweating at
night?
Signature ________________________________________________________________
Date ________________________________________________________________