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