Patient Contact Positions

Confidential Medical Information

Form to be returned to Occupational Health at least 2 weeks prior to start date

For patient contact positions (includes clinical workers, ward administrators, orderlies).

Please complete ALL sections. Please attach all previous occupational health screening results and immunisation records.

Immunisation record / previous blood test results: Some of these at least would have been done as pre-course screening e.g. medicine, nursing, allied health so should be available from your GP, student health or Occupational Health services of previous employers.

Hepatitis B - blood test results including both antibody level and surface antigen and any hepatitis B immunisation records

Chicken Pox - a declaration of a history of having had chicken pox OR blood test results OR proof of chicken pox immunisation

Measles - blood test results OR proof of x2 MMR immunisation

Pertussis- (whooping cough) - proof of your last immunisation

TB - Send any previous TB screening test results e.g. Mantoux, Quantiferon CXR results.

Failure to send the above may result in a delay in processing your Occupational Health clearance for employment

Note: For non-patient contact positions please complete the Health Declaration Non-Patient Contact Form.

If you have any questions about this form, please email RES-WorkplaceOHS@huttvalleydhb.org.nz.

Section A: Personal Details
Name *
Previous name(s)
Date of birth *
Ethnicity
Gender *
Address *
NHI number (if known)
GP practice or name *
Home phone number
Mobile phone number *
Email address *
Do you consent to health information being sent to the above email address? *
Position offered *
Ward/department *
Start date *
Manager *
Have you previously been employed by HVDHB? *
If yes, what year were you employed and what year did you resign?
Section B: Tuberculosis (TB)
1. Country of birth *
2. How long have you lived in New Zealand (in years and months)? *
3. If you have worked in a healthcare setting outside of New Zealand in the last two years, please state countries and length of time worked in each. 0/500 Words
4. Have you ever had a test for TB? (Quantiferon TB Gold or Mantoux) *
5. Have you had a recent chest x-ray related to TB screening or exposure? *
6. Have you had contact with TB without respiratory protection? *
7. Have you been part of a contact tracing exercise for TB? *
If you answered ‘Yes’, did you comply with all recommendations e.g. take prescribed medication or complete investigations?
8. Have you ever been diagnosed with TB or been given medication for TB? *
Details 0/500 Words
9. Do you have any medical condition or are you taking any medication which causes depression of your immune system e.g. renal failure, organ transplant, cancer, HIV or taking prednisone? *
Details 0/500 Words
10. Have you, in the last 2 years, experienced any of the following symptoms (lasting a month or more)? Tick all that apply.
Unexplained weight loss

Unexplained night sweats

Undiagnosed cough

Undiagnosed shortness of breath

Swellings under the arm or around the head/neck region
Section C: Infection Control

HVDHB screens staff for infectious diseases including chicken pox, measles and hepatitis B. If you do not have immunity vaccination is recommended – please discuss with Occupational Health.

HVDHB must know the hepatitis B status of clinical staff. This is important for the protection of patients, and workers in the event of future claims.
1. Measles - Do you have a documented record of having had two MMR immunisations? *
If you do not have a immunisation record, have you had a blood test for immunity?
2. Chicken pox - Have you ever had chicken pox? *
Have you ever been immunised against chicken pox or been tested for immunity?
3. Hepatitis B - Have you been immunised against Hepatitis B? *
Have you been screened for Hepatitis B? *
4. Influenza - have you been immunised against influenza? *
Date of last immunisation
5. Pertussis (whooping cough) - have you been immunised against pertussis? *
Date of last immunisation
6. Skin Assessment - Have you ever had a skin condition? *
Have you ever suffered from eczema/dermatitis?
Have you ever suffered from psoriasis?
Do affected areas include hands, arms, face, neck or head?
Details
Is it currently active?
Details
Are you currently having treatment for this?
Section D: Musculoskeletal

The position you have applied for may require you to perform tasks involving the following:
moving patients or objects, prolonged standing or sitting, pushing, pulling, reaching, bending, computer use, restraint of patients/clients or repetitive tasks.
1. Have you ever had a sprain or strain (back, neck, shoulder or arm) which has affected your ability to work for more than five days? *
2. Have you ever had any discomfort, pain or injury (back, neck, shoulder, arm or hand) which built up over time due to repetitive physical activity? *
3. Do you have any other musculoskeletal conditions (back, shoulders, legs, feet) that may affect your ability to work? *
If you answered yes to any of the above 3 questions, please give details including date, cause and diagnosis, ACC claims, time off work, and any residual problems: 0/500 Words
Section E: General Questions
1. Hearing - Do you have any hearing difficulties? *
Details
Have you previously worked in a noisy environment? *
Have you ever had a hearing test? *
2. Vision - Do you wear corrective lenses? *
Details
Do you have any vision difficulties aside from wearing glasses/corrective lenses? *
Details
3. In the last 5 years have you had a mental health problem, such as a diagnosed psychiatric or psychological condition, that required either: more than 1 week off work, treatment such as medication or counselling for more than 3 months, or hospitalisation? *
Details
4. Allergies or Sensitivities - Do you have any allergies or sensitivities? *
What is your allergy/ sensitivity to?
Details
5. Do you have any health issues that may affect your work? *
Details
6. Do you require any workplace modifications? *
Details
7. HVDHB has a smoke-free policy which prohibits workers and visitors from smoking anywhere in its facilities or grounds. If you smoke and would like assistance to quit, the Smoking Cessation Programme is available through Occupational Health or QUITLINE 0800 778 778. I would like occupational health to contact me to discuss the smoking cessation programme. *
Section F: Privacy and Declaration Statement

Clinical employees are reminded to consider their own risk of infection with blood-borne pathogens (hepatitis B, hepatitis C and HIV) and the associated risk of transmitting infection to patients. Professional bodies (NZ Medical Association, NZNO, Australasian College of Surgeons etc.) have statements relating to this, and workers should acquaint themselves with the appropriate association policies. Any employee who is a carrier of a blood-borne disease and knowingly exposes their patients to a risk of infection based on their own risk assessment, without seeking further counselling, could be open to disciplinary proceedings.

I declare to the best of my knowledge that the information I have given in this questionnaire is correct. I understand that giving false or misleading information or suppressing information may be a reason for disciplinary action to be taken against me if I am employed by HVDHB.
I understand that the information related to health screening will be placed on my Occupational Health file. I have a right to access this information and to obtain copies of my test results.
I consent to information regarding infection prevention and control, e.g. proof of immunity to specific infectious diseases and vaccination history, being passed on to Capital & Coast and Wairarapa District Health Boards for the purposes of pre-employment screening if required.

I consent to information on my personal immunity status and immunisation to be made available to my manager for the purposes of assisting with managing worker and patient safety, and for emergency planning and response purposes.

The information will be collected in accordance with the Privacy Act 1993 and the Health Information Privacy Code 1994. This declaration will be treated as a confidential medical record by HVDHB Health & Safety Service who will give recommendations to the relevant manager regarding fitness to work only. No medical details will be divulged to managers or any other employees in the organisation without the employee’s permission. If a workplace injury occurs in the future, insurers may, with the employee’s consent, request health information contained in this form to determine eligibility for cover.
The information will be used by HVDHB Health and Safety Service to identify and record the health status of personnel, fitness for work, identify reasonable workplace modification and provide a database for future occupational health issues.

While it is convenient to send information electronically and most of the information may not be highly sensitive, transmission of health information may not be secure and it is against HVDHB's privacy policy to transmit personal or sensitive information via unsecured external email. Once an email leaves a server it can be routed across multiple servers, maybe in several countries before delivery to your mail server. It(s) is not known where the email will travel, whose servers it may cross or how long it will be stored on those servers. There is a risk that unless e-mail messages are encrypted, confidential information and attachments sent via e-mail could be intercepted, accessed and read by third parties. If you have ticked “yes” and consented for health information to be sent to your private email address this confirms you are aware of the risks outlined above and that, whilst being aware of the risks, you wish to continue to have your information conveyed to you via e-mail. This confirms your authorisation of correspondence via unsecured email.
I have read and understood the above declaration statement. *
If you need to send evidence or attachments, please email them to RES-WorkplaceOHS@huttvalleydhb.org.nz

Confidential Medical Information

Section A: Personal Details

Section B: Tuberculosis (TB)

Section C: Infection Control

Section D: Musculoskeletal

Section E: General Questions

Section F: Privacy and Declaration Statement