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Health Screening Questionnaire

IMPORTANT NOTE: Before you commence completing this form, please ensure you have your immunisation/ Vaccination history, job role and health/medical information available as you may need this information in order to submit this form. You can obtain immunisation/vaccination evidence history from your GP practice and/or current or previous Occupational Health Department/s.
 
Once you commence completing this form there is no option to save. If you leave the form without submitting, you will need to re-start from the beginning.

Fields marked * are mandatory and must be completed to submit the form.

Personal Identifiable Information & Demographics

First name*:

Last name*:

Date of Birth (DD/MM/YYY]*:

Personal Address*:

Post Code*:

Mobile number*:

Email (Any correspondence will be sent to you by email)*:

National Insurance Number*:

Title*:

Comment:

Pronoun*:

Comment:

Sex (at birth)*:

Job Role

Please select your job role*:

Health Screening

Please read the following statements carefully and select the statement that best describes your current health status*:

Details:

Tuberculosis (TB) screening 

Only staff whose duties involve caring for patients or those who have social contact with patients in a clinical setting must complete this section.

Have you had any of the following: If the answer to any of the following questions is "yes" please give details.

Cough which lasted more than 3 weeks*:

Have you had any unexplained weight loss*: 

Have you had any investigations for Tuberculosis*:

Have you shared a home with a close family member/friend who has been diagnosed with TB?*:

Are you in regular contact with TB patients or clinical materials or have you worked in a high-risk clinical setting for 4 weeks or longer*:

Have you stayed in the UK continually for the last 5 years?*:

If no, please list all the countries you have visited, and the length of time spent there (failing to do this will result in you requiring an appointment):

Have you had a T-Spot Test/TB Quantiferon Blood Test since you have returned to the UK from the above Countries?*:

Have you had a Chest X-Ray with a report issued since arriving in the UK?*:

Have you had a BCG Vaccination?*: 

Do you have a BCG Scar that is visible?*:

If yes where is the scar?:

If you have answered "Yes" to any of the above please complete the comments section below:

Clinical Work Environment

In order to work in clinical areas as a volunteer you need to provide evidence that you have had: You can get this information via your G.P.

2 x MMR (measles, mumps, and rubella) vaccines
or positive blood test for measles and rubella. 

Please submit evidence to Occupational Health via email:

hwwb.bcp@sthk.nhs.uk

Email subject heading = job role & initials, example: Nurse – JS (if name is John Smith)

Job Role Risk Assessment

What is the patient contact requirement? (tick all that apply)*:

Details:

What is the potential exposure to infectious agents? (tick all that apply)*:

Details:

Do any of the below occupational tasks form part of the role? (tick all that apply)*:

Details:

Do any of the following workplace exposures apply to your role? (tick all that apply)*:

Details: