Health Declaration Form Step 1 of 4 25% Due to the nature of the role you have applied for we need to carry out an assessment of a new starter health questionnaire – even if you have been employed in UK health services before. The health of each candidate is considered individually and a decision regarding fitness for work in the prospective job role will be based on the functional effects of any underlying health condition/disability/impairment as well as health service requirements for fitness and immune status. Before health clearance is given for employment you may be contacted by telephone from a clinician at Healthier Business UK Ltd, however you may also need to be seen by an occupational health advisor/specialist or physician, arrangements for face to face consultations will be arranged by your employer or agency. We may recommend adjustments or assistance following an assessment to enable you to carry out your proposed duties safely and effectively. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice. Our aim is to promote and maintain the health of all individuals in the workplace: staff, service users and third parties. Your records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations. Your records will be held on file for the purposes of processing your request only and for no longer than is necessary, however your records may be subject to internal clinical audits. Your records may also be used to cross reference and ascertain your fitness should you register with other clients of Healthier Business UK Ltd. Name(Required) First Last Email(Required) GP Address (If known) Street Address Address Line 2 City County Post Code Do you have any illness/impairment/disability (physical or psychological) which may affect your work? Yes No Further Details:Have you ever had any illness/impairment/disability which may have been caused or made worse by your work? Yes No Further Details:Are you having, or waiting for treatment (including medication) or investigations at present? Yes No Further Details:Do you think you may need any adjustments or assistance to help you to do the job? Yes No Further Details:Have you suffered from methicillin resistant staphylococcus aureus (MRSA) Yes No Please state when:Have you suffered from clostridium difficile (C-Diff) Yes No Please state when: Have you ever had chicken pox or shingles? Yes No Unsure Please state when:Have you ever come into contact with any BBV’s? Including Needle Stick Injuries? Yes No Unsure Have you lived outside the UK or had an extended holiday outside the UK in the last year? Yes No please list all the countries that you have lived in/visited over the last year, including holidays and vacations. This MUST include duration of stay and dates or this form will be rejected.(Required)Have you had a BCG vaccination in relation to Tuberculosis? Yes No Unsure Please state when: Do you have a cough which has lasted for more than 3 weeks? Yes No Further Details:Do you have unexplained weight loss? Yes No Further Details:Do you have unexplained fever? Yes No Further Details:Have you had tuberculosis (TB) or been in recent contact with open TB? Yes No Further Details:Have you had the triple vaccination as a child (Diphtheria, Tetanus, Whooping Cough)? Yes No Unsure Please state when:Have you had the Polio vaccination? Yes No Unsure Please state when:Have you had a Tetanus vaccination? Yes No Unsure Please state when:Have you had the Hepatitis B vaccination? Yes No Unsure Please state when:Will your role involve Exposure Prone Procedures? Yes No Unsure All information supplied by you will be held in confidence by Healthier Business UK Ltd. Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. Your data may also be cross referenced should you have registered with other clients of Healthier Business UK Ltd. Your personal data may be required to be seen by an occupational health advisor or physician; however it will not be shown, nor their contents shared with anyone – including Managers, Human Resources Advisors, GP’s, Specialists or third party’s – without your explicit consent. You have the right of erasure (the right to be forgotten), refusal of consent and withdrawal of consent without detriment (withdrawal of consent can be exercised at any stage of the process). The only exceptions to this may be a court order for release of records in a judicial dispute or where there is a public responsibility obligation. Further information regarding your rights under GDPR can be found on the following: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/ If you wish to have sight of our privacy policy, please send your request to support@hbcompliance.co.ukConsent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed. You have the right to withdraw your consent at any stage of the process, either verbally or in writing. Further information regarding consent is available on the ‘Candidate Screening Leaflet’. Do you consent to this questionnaire and your immunisation reports being assessed by an Occupational Health Advisor for the purpose of providing a Fitness to Work Certificate? Yes No Do you consent to our Occupational Health Advisors speaking with you regarding any declaration you may have made relating to your medical history? Yes No Do you consent to our Occupational Health Advisors making recommendations to your employer/agency to assist with your ability to carry out your prospective role? Yes No Declaration(Required) I agree.Declaration I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. Signature
