Occupational Health - Special Staff Status Health Declaration

Confidential Medical Information

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

Form to be received by Occupational Health at least two weeks prior to start date

This questionnaire must be completed by all visitors entering HVDHB premises for professional reasons without a contractual arrangement e.g. visiting medical personnel, clinical observation, researchers.

Along with this completed special staff status form, please send through your vaccination record or serology proof of immunity to Measles, Mumps, Rubella, Hep B, and proof of Boostrix/Tdap vaccination in the last 10 years.

All visitors must be sponsored by a senior HVDHB staff member. The sponsor is responsible for the visitor while they are at HVDHB and must ensure that the visitor complies with all health and safety requirements of HVDHB including infection prevention and control.

Section A: Visitor's Details
Visitor's name *
Visitor’s email address
Visitor's phone number
Purpose of visit (describe in detail the activities/duties to be undertaken) *
Date *
How long will you be at HVDHB? *
Section B: Sponsor's Details
Sponsor’s name *
Sponsor’s position *
Sponsor’s phone number *
Section C: Visitors who will have patient contact to complete
1. Do you regularly have patient contact in other healthcare settings?
2. Have you kept up to date with your occupational health screening requirements for infectious diseases, including tuberculosis, hepatitis B, measles and chicken pox, including contact tracing and vaccination requests?
3. Have you complied with all vaccination recommendations and contact tracing requirements?
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 H&S or infection control requirements asked of you by HVDHB 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 *
Start Date *

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

Declaration Statement