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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@bcf.nhs.uk

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 ________________________________________________________________