Occupational Health - Special Staff Status Health Declaration

Confidential Medical Information

Form to be returned to Occupational Health at least 2 weeks prior to start date, but do not submit more than 2 months prior to your start date as we do not have the capacity to hold these longer than this.

This questionnaire must be completed by all visitors entering TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY premises for professional reasons without a contractual arrangement e.g. visiting medical personnel, clinical observation, and researchers.

All visitors must be sponsored by a senior TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY staff member. The sponsor is responsible for the visitor while they are at TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY and must ensure that the visitor complies with all health and safety requirements of TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY including infection prevention and control.

If you have any questions about this form, please email us RES-PreEmpScreening@ccdhb.org.nz

Section A: Visitor's Details
First names *
Surname *
Previous name(s)
Date of birth *
Country of birth *
Gender
Address *
Mobile phone number *
Personal email address *
NHI number (if known)
Purpose of visit (describe in detail the activities/duties to be undertaken) *
Start date *
Finish date *
How long will you be at TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY? *
Section B: Sponsor's Details
Sponsor’s name *
Sponsor’s position *
Sponsor’s phone number *
Hospital Base (eg Wellington, Hutt, Kenepuru)
Section C: Visitors who will have patient contact to complete

TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY expects you to be able to provide (if required for contact tracing) documentation of; Hepatitis B (AntiHBs >20 iu/L), Measles (2 x MMR vaccination record or serology report), Chickenpox (history of disease or 2 x vaccination record), and Pertussis (record of vaccination received in the past 10 years).

TE WHATU ORA – CAPITAL, COAST AND HUTT VALLEY has an expectation that those wanting special staff status to carry out work in a clinical setting will be fully vaccinated for covid.
Do you regularly have patient contact in other healthcare settings? *
If 'Yes' have you kept up to date with your occupational health screening requirements for infectious diseases, including tuberculosis, hepatitis B, Measles and Chicken Pox? *
Do you consent to your Covid-19 immunisation records being viewed for the purpose of this clearance? *
Section D: Declaration Statement

Health and Safety and infection control is extremely important with the hospital setting. There is both a higher risk from you possibly exposing others to any infection that you carry and also a higher risk that you may be exposed to an infectious disease from others within the hospital.

Because of this we require an undertaking from you that you will not enter the hospital environment for work purposes or as an observer if you are suffering a potentially contagious disease. The main routes of exposure to an infectious disease are having direct skin to skin contact with other people or via contaminated surfaces, or airborne spread from breathing contaminated air or droplet spread (e.g. coughing or sneezing).

We therefore require you to agree to this statement that you will not enter the hospital if you have an infectious disease or any symptoms such as fever, cough, cold, skin infection, or skin condition that is causing significant skin flaking. You must also follow any Health and Safety or infection control requirements asked of you by TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY staff members. If you have any questions or are uncertain then please contact the Occupational Health Nurse for further discussion and advice.
I have read the above statement and I agree to abide by the requirement not to enter the hospital with any infectious disease or symptoms as listed above *

Last updated 6 November 2023.

Occupational Health - Special Staff Status Health Declaration

Confidential Medical Information

Section A: Visitor's Details

Section B: Sponsor's Details

Section C: Visitors who will have patient contact to complete

Section D: Declaration Statement