Gesundheitsfragebogen E - Universitätsspital Basel

unispital.basel.ch

Gesundheitsfragebogen E - Universitätsspital Basel

Human Resources

Date: 10.02.2011

Author: D. Margelli Hartmann

Page: Page 1 of 2

File:

Gesundheitsfragebogen_MANUS_1

Health questionnaire for new staff Staff medical service

The purpose of this health questionnaire (see reverse) is to clarify whether any measures need to

be taken to protect your health while you are employed at the hospital. We kindly ask you to fill in the

questionnaire and send it back to us, together with copies of your vaccination documents, within

one week after starting your job. The information you provide is confidential, apart from the

questions concerning hospital hygiene.

We will send you a written notification within a few days after we have received your form back from

you. If required, or at your request, we will invite you to an introductory consultation.

Thank you! We wish you a successful start to your career at USB!

The staff medical service team

Medical Director:

Nursing team:

Dr. med. Daniela Margelli Hartmann

Astrid Recher

Ruth Zaugg

You can find more information on our Intranet site under:

>> Infocenter >> Personalarztdienst [staff medical service]

Return address

Internal mail

PERSONALARZTDIENST

Universitätsspital Basel

Hebelstrasse 2

CH – 4031 Basel


Human Resources

Date: 10.02.2011

Author: D. Margelli Hartmann

Page: Page 2 of 2

File:

Gesundheitsfragebogen_MANUS_1

Health questionnaire for new staff Staff medical service

Personal details (please write in block capitals)

Surname

Date of birth

Workplace at USB

Position at USB

First name

USB telephone no.

Starting date

Previous employer

Have you previously worked at USB q at the University Psychiatric Clinic (UPK)? q

at REHAB Basel ?q No q

Medical history No Yes (please describe)

Have you suffered from any illnesses or disorders

in connection with your professional activities?

Do you have any allergies/skin conditions?

Have you had chickenpox (varicella)?

q

q

q

q

q

q

Are you taking any medication which could affect

your ability to work?

q

q

Questions concerning hospital hygiene No Yes

Do you have direct contact with patients at Universitätsspital Basel?

Did you have direct contact with patients at your previous place of work?

Was your last job outside German-speaking Switzerland?

Have you previously been diagnosed with/undergone treatment

or decolonisation for MRSA?

I would like to make an appointment for a medical consultation

q

q

q

q

q

q

q

q

q

q

Please attach copies of vaccination cards and available laboratory results

(Hepatitis B antibodies, varicella/chickenpox, measles, mumps, rubella, tuberculosis blood tests)

Place, date:

Signature:

Opening times: Monday, Tuesday and Thursday, 8.00 – 11.30 and 13.00 – 16.00 hrs

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