Hutt Valley DHB Logo

(04) 566 6999

Confidential Medical Information

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

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 (for patient facing roles only)

Covid – 19 - Please provide records of your Covid – 19 vaccinations.

­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

If you have any questions about this form, please email


Please complete the form on a PC / computer device. Don't complete on a phone or tablet. We recommend not using a ThinkPad device to complete the form.

  • Section A: Personal Details

  • Section B: Tuberculosis (TB)

  • 0/500 Words
  • 0/500 Words
  • 0/500 Words
  • 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.

  • 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.

  • 0/500 Words
  • Section E: General Questions

  • Section F: Privacy and Declaration Statement

    The pre-employment health assessment forms part of a screening process designed to ensure that all new staff are fit to perform the duties and tasks of the job they have been offered.

    The information collected during the assessment will be appropriate to the area in which employment is offered. Your future manager has indicated which hazards and potential risks you may be exposed to and appropriate screening will be carried out accordingly.

    In the event that you have any medical or health related condition(s) that are:

    • likely to affect or limit your ability to carry out the full requirements of the position you have been provisionally offered; or
    • that may be aggravated by the tasks of that position; and/or
    • you are certified as being “unfit for work” by a registered medical practitioner during a pre-employment assessment,

    You accept that HVDHB may elect to withdraw the offer of employment or terminate your employment (where the offer has already been accepted by you), unless the position can be reasonably altered or the workplace modified in order to reduce the risk of harm or injury to yourself or others.

    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.

  • If you need to send evidence or attachments, please email them to