ࡱ> 6:345{ bjbj Goff1FF8$,PBnd$'Lp'p''+<D,,Tlllllll$psl<-**@<-<-lp''@m,000<-Fp''l0<-l00.`sfp'jN-jc@ln<Bnct-Htsfsf|tf<-<-0<-<-<-<-<-ll4/T<-<-<-Bn<-<-<-<-t<-<-<-<-<-<-<-<-<-FX : All members of College who will have contact with patients or young children in their work or studies must complete a health assessment. Its purpose is to ensure that you can be appropriately protected against infections you may encounter in your work or that you might pass on to vulnerable patients and children. You should also disclose any health condition or disability that may affect you in your work so that appropriate measures to provide support or limitany risk to you or others can be put in place. All members of College who will have contact with patients or young children in their work or studies must complete a health assessment. Its purpose is to ensure that you can be appropriately protected against infections you may encounter in your work or that you might pass on to vulnerable patients and children. You should also disclose any health condition or disability that may affect you in your work so that appropriate measures to provide support or limit any risk to you or others can be put in place. Data Protection information The information that you supply on this questionnaire will be held in confidence by the College Occupational Health Service as part of your Occupational Health record, please refer to the Occupational Health Privacy Notice:  HYPERLINK "http://www.imperial.ac.uk/occupational-health/privacy-notice" www.imperial.ac.uk/occupational-health/privacy-notice 1: Personal details Title:  FORMTEXT       Family name:  FORMTEXT       FORMTEXT       Given names(s):  FORMTEXT       FORMTEXT       CID:  FORMTEXT       Date of Birth:  FORMTEXT       FORMTEXT       Gender:  FORMTEXT       Job title:  FORMTEXT       FORMTEXT       Faculty:  FORMDROPDOWN  Dept or Division:  FORMTEXT       FORMTEXT       Section:  FORMTEXT       FORMTEXT       Campus:  FORMDROPDOWN  Daytime phone no:  FORMTEXT       FORMTEXT       E-mail:  FORMTEXT       2: Support needs Do you have any health condition or disability for which you require adjustments or specific support in order to help you carry out your work or which could adversely affect the safety or well-being of patients or children in your care? yes  FORMCHECKBOX  no  FORMCHECKBOX  If yes, please give details of adjustments or other support you will require to accommodate these: FORMTEXT       3: Tuberculosis health screen Have you lived continuously in the UK for the past 5 years? yes  FORMCHECKBOX  no  FORMCHECKBOX  If no, which countries have you lived in during the past 5 years?  FORMTEXT       Has any member of your family had tuberculosis in the past 5 years? yes  FORMCHECKBOX  no  FORMCHECKBOX  In the past 2 months have you experienced any of the following: Persistent cough (lasting more than 3 weeks) yes  FORMCHECKBOX  no  FORMCHECKBOX  Persisting malaise, fatigue or loss of appetite yes  FORMCHECKBOX  no  FORMCHECKBOX  Coughing up blood yes  FORMCHECKBOX  no  FORMCHECKBOX  Episodes of profuse sweating during the night yes  FORMCHECKBOX  no  FORMCHECKBOX  Unexplained fever yes  FORMCHECKBOX  no  FORMCHECKBOX  Unexplained weight loss (more than 4kg.) yes  FORMCHECKBOX  no  FORMCHECKBOX  Swollen glands yes  FORMCHECKBOX  no  FORMCHECKBOX  Details if  yes :  FORMTEXT       4: Additional Questions for clinical staff 1. Details of work: 1.1 General contact with patients. yes  FORMCHECKBOX  no  FORMCHECKBOX  1.2 Infectious disease unit..... yes  FORMCHECKBOX  no  FORMCHECKBOX  1.3 Surgical or obstetrics unit... yes  FORMCHECKBOX  no  FORMCHECKBOX  1.4 Oncology or paediatrics unit... yes  FORMCHECKBOX  no  FORMCHECKBOX  2. Will you require an honorary NHS contract? yes  FORMCHECKBOX  no  FORMCHECKBOX  3. Have you been in continuous NHS employment in the past 5 years? ..yes  FORMCHECKBOX  no  FORMCHECKBOX  4. Will your work involve handling or taking blood / specimens?...yes  FORMCHECKBOX  no  FORMCHECKBOX  5. Will you require Exposure Prone Invasive Procedure clearance?....................................................... yes  FORMCHECKBOX  no  FORMCHECKBOX  5: Immunisation information Please complete the table below & provide supporting documentary evidence if available Notes ALL who will have contact with patients: Please provide information on your immunisation history below. If you have had any tests to check your immune status provide copies of laboratory reports or certified statements obtained from your current occupational health service or family doctor as evidence. This will speed up your clearance and will avoid unnecessary repetition of tests. If you hold the information on an NHS smart card, please obtain a print out of this and have it validated by your current OH Service. Surgical work: If you will be involved in surgery or other exposure-prone procedures you will need to be tested for blood-borne viral infection unless you can provide certified proof of tests from previous employment in the NHS. NHS honorary contracts: Note that you cannot be issued with an NHS honorary contract to begin clinical duties until you have completed or provided documentary proof to the College OH Service of all necessary tests or vaccinations required under the issuing Trusts control of infection policies. Early Years Staff/ other child care workers/ Please provide information on BCG vaccination, MMR immunisation or tests for immunity against measles, mumps, rubella and TB, plus information on chickenpox (infection or vaccination). If you are unsure, please check with your GP. You do not need to provide information on other vaccinations or blood tests Have you had:YesNoDATES of test or vaccinationDocumentary evidence supplied?NotesTB immunity test* (Heaf or Mantoux test) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX BCG vaccination* FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX Exact date of vaccination required.Chickenpox infection or shingles*  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX Self- declared history of illness sufficient evidence of immunity unless you lived in a tropical country during childhood.Varicella (VZV) antibody test* FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX Varicella/chickenpox vaccination*  FORMCHECKBOX  FORMCHECKBOX 1st FORMTEXT       2nd FORMTEXT      Yes  FORMCHECKBOX 2 doses required for immunity.MMR immunisation* FORMCHECKBOX  FORMCHECKBOX 1st FORMTEXT       2nd FORMTEXT      Yes  FORMCHECKBOX If you will have patient contact you must have had 2 doses of MMR vaccine unless you have serological proof of immunity to measles & rubella.Rubella antibody test* FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX Antibody tests are not required if you have documented evidence of two MMR vaccinations.Measles Antibody test* FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX Mumps antibody test* FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX Hepatitis B immunisation*  FORMCHECKBOX  FORMCHECKBOX 1st  FORMTEXT       2nd:  FORMTEXT       3rd:  FORMTEXT       Booster:  FORMTEXT      Yes  FORMCHECKBOX Give dates of when you completed your initial course of immunisation & of your last booster, if applicable.Hepatitis B antibody test* FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX Diphtheria immunisation FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX Vaccine may be combined with tetanus and polio. HIV antibody test** FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX Reports certified by an Occupational Health Service as an identity-verified sample (IVS) may be needed to obtain clearance for surgical work The College OH Service will arrange a test if necessary during your first week at College.Hepatitis B Surface Antigen Test** FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX Hepatitis C antibody test** FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX * Documentary evidence of immune status or vaccination required for NHS clearance. ** Documentary evidence of immune status required before clearance for surgical work can be given. 6: Patient Sh . ; w ;   ͻͻͭ|n\NNh `CJOJQJ^JaJ#jh `CJOJQJU^JaJhqCJOJQJ^JaJ#h `hq5CJOJQJ^JaJ hqhqCJOJQJ^JaJhunCJOJQJ^JaJh}CJOJQJ^JaJ#hp{hunCJOJQJ]^JaJ hp{hunCJOJQJ^JaJ hp{h_GGCJOJQJ^JaJ hp{h8CJOJQJ^JaJ ;  Jxwwn!]!gdUD r / y%gdp{ r / y%xgdUD / y%xxgd_h%d-DM O]gd `:$ $PP$d%d&d'd-DM NOPQa$gd `  F H I ~    ϼ᫢|nX|@@@@@|/jhehe>*OJQJU^JmHnHu*jhehe>*OJQJU^Jhehe>*OJQJ^J$jhehe>*OJQJU^JheOJQJ^Jh `hW^Jhw!hUD^J hqhqCJOJQJ^JaJ$h1Hh `0JCJOJQJ^JaJ#jh `CJOJQJU^JaJh `CJOJQJ^JaJ hqh `CJOJQJ^JaJ 8:<PRTVXZ\^`bvxz|~ŷʼnŷsʼnfYOhSTOJQJ^Jh>+ϴ>ϴ*>>*ϴ/>>*ϴԱ*ᱹ>>*ϴ>>*ϴ$>>*ϴϴϴ>ϴ+ϴ"$8:<̾̐̾z̐pf̾P*jNhehe>*ϴ󳧰ϴ+ϴ*>*ϴ/>*ϴԱ*>*ϴ>*ϴ$>*ϴϴϴ>ϴ<>@BDFHJdhj~ʽԣԣwmcYh>OJQJ^Jho+WOJQJ^JheOJQJ^J*j:hehe>*OJQJU^J*jhehe>*OJQJU^Jhehe>*OJQJ^JheCJOJQJ^Jh>hUDOJQJ^Jh_OJQJ^J$jhehe>*OJQJU^J/jhehe>*OJQJU^JmHnHu &*,@ưԘ猀sgTFheh( >*OJQJ^J$jheh( >*OJQJU^Jh( CJOJQJ^Jh>hUDOJQJ^Jh>CJOJQJ^Jho+WCJOJQJ^J/jhehe>*OJQJU^JmHnHu*jhehe>*OJQJU^Jhehe>*OJQJ^J$jhehe>*OJQJU^JheCJOJQJ^Jh>heOJQJ^J@BDFHJLNPRfhjlnprtvx׿ױ׿׌lUC#h( hUD>*CJOJQJ^JaJ,jh( hUD>*CJOJQJU^JaJ%hhUDB*CJOJQJ^Jphh>hUDOJQJ^JhhUDCJOJQJ^J*jheh( >*OJQJU^Jheh( >*OJQJ^J/jheh( >*OJQJU^JmHnHu$jheh( >*OJQJU^J*j&heh( >*OJQJU^J  ,÷~pZ~BBBBB~~p/jh>h( >*OJQJU^JmHnHu*jJh>h( >*OJQJU^Jh>h( >*OJQJ^J$jh>h( >*OJQJU^Jh>h( OJQJ^Jh>hUDOJQJ^Jh>CJOJQJ^Jho+WCJOJQJ^Jh( CJOJQJ^J,jh( hUD>*CJOJQJU^JaJ2jh( hUD>*CJOJQJU^JaJ,.02468:<>DN^`bvxz|~׿ײ׀j׿׀T׿*jh>h( >*OJQJU^J*j6h>h( >*OJQJU^Jh>h( >*OJQJ^Jh>hUDOJQJ^Jh>OJQJ^Jh>ho+WOJQJ^Jh>h( OJQJ^J/jh>h( >*OJQJU^JmHnHu$jh>h( >*OJQJU^J*jh>h( >*OJQJU^J .02ϸ{naS=*j h>h( >*OJQJU^Jh>h( >*OJQJ^Jh>h( OJQJ^Jh>ho+WOJQJ^J h>h( CJOJQJ^JaJ2j"h>hUD>*CJOJQJU^JaJ#h>hUD>*CJOJQJ^JaJ,jh>hUD>*CJOJQJU^JaJ!h>hUDB*OJQJ^Jphh>hUDOJQJ^J$jh>h( >*OJQJU^J2468:<>@TVXZ\^`bdfn|~ưԣ}j\Fj*j| heh( >*OJQJU^Jheh( >*OJQJ^J$jheh( >*OJQJU^Jh>h( CJOJQJ^Jh>hUDOJQJ^Jh>OJQJ^Jh>h( OJQJ^J*j h>h( >*OJQJU^Jh>h( >*OJQJ^J$jh>h( >*OJQJU^J/jh>h( >*OJQJU^JmHnHuɷq[J1[0j hUDhnB*OJQJU^Jph!hUDhEB*OJQJ^Jph*jhUDhnB*OJQJU^Jph%hUDhEB*CJOJQJ^Jph(hUDhunB*CJOJQJ]^Jph%hUDhunB*CJOJQJ^JphhUDhECJ^J#h `h `>*CJOJQJ^JaJh `>*OJQJ^J$jheh( >*OJQJU^J/jheh( >*OJQJU^JmHnHuŬ엁iNi11111i9jhUDhD[B*CJOJQJU^JmHnHphu4j hUDhnB*CJOJQJU^Jph.jhUDhnB*CJOJQJU^Jph+hUDhun6B*CJOJQJ]^Jph(hUDhunB*CJOJQJ]^Jph0jh hUDhnB*OJQJU^Jph!hUDhEB*OJQJ^Jph*jhUDhnB*OJQJU^Jph%hUDhEB*CJOJQJ^Jph2 QvRR$ & F 9r 7$ 7W<1$5$7$8$9DH$^7`Wgd_GG% & F 9r 7>$ 7W<1$5$7$8$9DH$^7`WgdK% & F 9r 7$7W<1$5$7$8$9DH$^7`Wgd_GG]gdE & F 9r $x1$5$7$8$9DH$gdE & F $x1$5$7$8$9DH$gd>2 Z\h˼{h{Rh{ChUDha& CJOJQJ^J+j hUDhnCJOJQJU^J%jhUDhnCJOJQJU^JhUDhECJOJQJ^J'jT hUDhnOJQJU^JhUDhEOJQJ^J!jhUDhnOJQJU^JhUDhCJOJQJ^JhUDhCJ^JhUDhB CJ^JhUDhECJ^J%hUDhEB*CJOJQJ^Jph%&'56οΐ΄uuuhWJ6'j hUDhnOJQJU^JhUDhEOJQJ^J!jhUDhnOJQJU^JhUDhOJQJ^JhUDhCJOJQJ^JhKCJOJQJ^J0jhUDhD[CJOJQJU^JmHnHu+j@ hUDhnCJOJQJU^JhUDhECJOJQJ^J%jhUDhnCJOJQJU^JhUDhE5CJOJQJ^JhUDh=CJOJQJ^J67>?#$234<=KLMNeftűŝʼnua'jhUDhnOJQJU^J'jhUDhnOJQJU^J'jhUDhnOJQJU^J'jhUDhnOJQJU^J'j,hUDhnOJQJU^JhUDhEOJQJ^JhUDhOJQJ^JhUDhCJOJQJ^J!jhUDhnOJQJU^J#N`1ss 9r $ <1$5$7$8$9DH$gd> 9r $ <1$5$7$8$9DH$gd(n 9r >$ <1$5$7$8$9DH$gd>'dQ]gdq $hdh^hgd@+! 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If you know that you have, or think that you might have, a serious condition that you could pass on to patients, or if your judgment or performance could be affected by a condition or its treatment you must declare this in confidence to the College Occupational Physician. If aspects of your work may involve a risk of transmitting an infection to patients, you must not carry out such work until the risk has been assessed and any necessary measures to prevent transmission agreed and implemented. If your work involves you undertaking or assisting with surgical or other  exposure prone procedures you cannot be passed fit for work until the College s OH Advisers have obtained satisfactory documented evidence of your Hepatitis B status or other tests necessary to comply with relevant NHS Trusts Control of Infection policies. You must also inform Occupational Health if you have ever had a positive test indicating infection with a transmissible blood-borne virus infection such as Hepatitis B, Hepatitis C or HIV. DECLARATION I have read the above and agree to comply with the College Patient Safety Code. Signature:  FORMTEXT       FORMTEXT       FORMTEXT       Date:  FORMTEXT       FORMTEXT       7: Declaration Please sign the declaration below. Before signing, make sure that you have answered all questions as instructed, providing further details as required. I declare that the information I have provided on this form is true and complete to the best of my knowledge and belief. Signature:  FORMTEXT       FORMTEXT       FORMTEXT       Date:  FORMTEXT       FORMTEXT       Once you have completed your questionnaire, please send it to: Occupational Health Imperial College London SW7 2AZ Forms may be submitted by e-mail to: occhealth@imperial.ac.uk If you need any more vaccinations or tests to complete health clearance for your work, you will be sent an appointment to attend the College OH Clinic on the South Kensington campus during your first week of employment. For OH Use only Fit for IC (date and initial): or Identification Verification: Passport  FORMCHECKBOX  Photo Driver s License  FORMCHECKBOX  Fit for IC + NHS Hon. 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