Pre-Employment Health Assessment - Royal Bournemouth Hospital

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The Royal Bournemouth andChristchurch HospitalsNHS Foundation TrustCONSENT TO APPLY FOR AND RELEASE OF PERSONAL MEDICAL INFORMATIONUNDER THE ACCESS TO MEDICAL REPORTS ACT (AMRA) 1988INFORMATION SHEETThe Occupational Health Nurse/Physician may wish to write to your doctor to request a medical report on you (yourdoctor being your family doctor or, in the case of hospital treatment, your hospital specialist). The consent formrequests your formal consent and it will be forwarded to your doctor at the time of application for information.Under the terms of the Access to Medical Reports Act 1988 you have the following rights:ABCDEFGHYou can refuse to give consent.If you do give consent you have the right, if you wish, to see the Doctors report before it is sent to theOccupational Health Department.If you opt to see the report you must ask your doctor for sight of it within 21 (twenty-one) days of thedate on which it was requested (you will be told in writing what that date is). If you fail to meet thisdeadline the report (providing you have given consent) will be sent automatically to the OccupationalHealth Department.When you have seen the report you have the right, if you wish, to withdraw your consent to it being sent.If you consider any of the information contained in the report to be incorrect or misleading you can askfor it to be amended. However, you must do this in writing. If your doctor does not agree that theinformation is misleading or incorrect he /she does not have to amend the report. Instead you will beinvited to prepare a written statement giving your views of the disputed information. This statement willbe included when your GP / Specialist sends the report to the Occupational Health Department.You will continue to have right of access to the report for up to 6 (six) months after it has been sent tothe Occupational Health Department. If, within that six month period you wish to see the report you mustfirst obtain permission from your doctor as the Occupational Health Department cannot disclose thereport to you.If you just want to see the report it will cost you nothing but if you wish to have a copy for your recordsyour doctor may charge a fee for this service.Your doctor has the right to withhold from you any information, which he/she considers may causeserious harm to your physical or mental health. In some cases the doctor may allow you to see only partof the report.The information provided in the medical report will be retained by the Occupational Health Department on aconfidential basis and any advice given to management will be expressed in terms of fitness for employment and/orfitness to carry out duties both now and in the future, having considered the information provided by your GP/Specialist.Please contact the Occupational Health Department if you have any queries.FORMS/Pre Employment Health Questionnaire Version 2 14 July 2010 6
FOR OFFICIAL USE ONLYWhat is your height: ……………… What is your weight: …………… BMI: …………Are you a smoker? YES / NO How many do you smoke per day? ……………….Are you an ex-smoker? YES / NO How many did you smoke? ……………….VISUAL ACUITY ( R ) ( L ) ISHIHARA TESTNEAR VISIONDISTANCE VISIONMIDDLE VISIONSICKNESS IN THE LAST TWO YEARS:BLOOD PRESSURE:URINALYSIS:COMMENTS:Bloods taken for: Hep B Abs Hep B Core Hep CRubella Varicella MeaslesHep B Surface AntigenHIVBCG scar seen:Site (signature):Date seen by OH Nurse / Doctor:FitUnfitFit within limitation stated:SIGNATURE: ………………………………………… DATE: …………………….Occupational Health Doctor/Nurse)FORMS/Pre Employment Health Questionnaire Version 2 14 July 2010 7
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