Pre-Employment Health Assessment - Royal Bournemouth Hospital

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IMMUNISATION YES NO DON’T KNOW DATES TEST RESULTSHave you ever worked or lived abroad? If so please give detailsDPT (Diptheria, Tetanus,Polio)MMR 1 st Dose2 nd DoseTB test (Mantoux)TSPOTBCG (TB vaccination)Chicken pox (varicella)Hepatitis AHepatitis B Vaccinations:123Antibody Blood TestBooster VaccinationAntibody blood TestDECLARATION:I confirm that all the answers given above are true to the best of my knowledge and have beenrecorded accurately. I understand that any information, which is found to be deliberately inaccurate oromitted, may subsequently lead to a review of my employment situation and / or my dismissal.Signature:Date:FORMS/Pre Employment Health Questionnaire Version 2 14 July 2010 4
The Royal Bournemouth andChristchurch HospitalsNHS Foundation TrustCONSENT TO APPLY FOR AND RELEASE OFPERSONAL MEDICAL INFORMATIONIn some circumstances we may wish to contact your GP or Specialist for further information about your health. Inorder to approach your GP or Specialist, please provide the following information:About yourselfSurname:First name(s):Date of Birth:Telephone No:Full address:Post Code:About your Family Doctor (GP)Name:Telephone No:Full address:Post Code:About your Hospital Specialist (if applicable)Name:Hospital number:Department:Full address:Post Code:DECLARATIONI consent / I do not consent (delete as appropriate) to my GP and / or Specialist providing the OccupationalHealth Department with a medical report or / and a copy of my medical records.I do wish / do not wish ( delete as appropriate ) to see the report / records before it is sent to theOccupational Health DepartmentI have received the Access to Medical Reports Act Consent Information Sheet and I understand the informationgiven will be retained by the Occupational Health Department on a confidential basis and that any advice givento management will be expressed in terms of my fitness for employment and /or my fitness to carry out my dutiesboth now and in the future.Signature:Date:FORMS/Pre Employment Health Questionnaire Version 2 14 July 2010 5
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Pre-Employment Health Assessment - Royal Bournemouth Hospital

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