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, proof of Boostrix/Tdap vaccination in the last 10 years, and proof of Covid Vaccination.
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.
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.