Work Health Assessment Questionnaire

Nottingham Occupational Health 2010 NUH NHS
Guidance for completion the Work Health Assessment Questionnaire
Congratulations on being offered the post you have recently applied for. As stated in your offer letter, this post is
subject to a satisfactory Work Health Assessment by the Occupational Health Service.
The purpose of Work Health Assessment is to ensure that you are well enough for the proposed job and to advise you
manager whether you will require any additional help or support to perform the job if you have a medical condition or
disability. It is essential that you answer all questions fully and give plenty of additional information if you think your
health may affect your work; this way we can advise your manager of any reasonable adjustments that may be
required.
We respect your confidentiality and comply with the Data Protection Act 1998 and other relevant legislation. Your form
will be assessed by an Occupational Health Professional and we assure you that confidential information will not be
disclosed to a third party without your express consent. Where we have to examine your personal information for
audit purposes, we will not reveal confidential information in any audit report. Specific guidance about the
Questionnaire is provided below:
Section 1:
Personal Details
Completing all sections will help us identify and link you to the post you have been offered. Please only provide
contact details that you are happy for us to use as part of the Work Health Assessment and after you start. If we have
to write to you it will usually be to your home address or email address. Please note that we will not leave voicemail
messages or emails that reveal personal confidential information. If we speak to you by telephone we will confirm
your identity before asking any personal questions.
Please let us know the details of the job you have been offered and who your manager will be. This will help us to
assess your health according to the work you may perform. Also please let us know if you have previously trained
with us, or worked in the NHS before. This is especially important for nursing, medical and midwifery posts, as it may
affect the type of screening required for your post.
Please help us to help you by completing the questionnaire as fully as possible. Please complete this form in BLACK
pen / typeface and block capitals
Title: Ms / Miss / Mrs / Mr / Dr / Professor:
Surname/Family name:
Male
First name(s):
Female
Previous names (if applicable): Date of birth:
Home Address:
Post code:
Email Address:
Mobile: Tel home:
Name of GP:
Address of General Practitioner:
Proposed Job Title: Manager (if known):
Department: Campus:
Have you ever worked/trained here? Yes No Are you new to working for the NHS? Yes No
Name and address of present employer
Present post

Section 2:
Work Health Questionnaire – for all posts
These questions have been designed to allow you and us to assess your health and wellbeing in relation to the job
you have been offered. If you have a health condition or disability that may affect your work, you should disclose it
fully here. In particular, health problems that may affect work tasks or be affected by work patterns such as night or
shift work, or certain working environments, should be disclosed and you should give as much information as you can
about how this condition affects you in everyday life and at work, any treatment or investigations you may have had or
are awaiting and any workplace adjustments that my help or have worked in the past.
Please attach additional sheets of paper if necessary.
All staff groups complete this section
1. Do you have any illness/impairment/disability (physical or psychological) which may affect your
ability to work? Conditions which could be relevant include:
• Infective illness
• Back or Joint problems
• Skin problems
• Epilepsy
• Diabetes
• Mental Health illness
• Heart Disease
• Problems with hearing or vision not corrected by hearing aids glasses, lenses or
If yes, please give details below Yes No
2. Have you ever had any illness/impairment/disability which may have been caused or made worse
by your work?
If yes, please give details below Yes No
3. Are you having, or waiting for treatment (including medication) or investigations at present?
If yes, please give details below Yes No
4. Do you think you may need any adjustments or assistance to help you to do the job?
If yes, please give details below Yes No

Section 3:
Prevention of occupationally acquired diseases and ill health – for posts with direct patient
contact of handling specimens
If your work involves direct patient contact or handling clinical specimens you may be at risk of acquiring or
transmitting particular infections. In addition to this we have a duty to ensure that all clinical staff are protected against
developing occupational diseases such as dermatitis and asthma. We will assess the information you provide with the
immunisations and health monitoring required for the post according to national and local policies. If you require
additional immunisations or blood tests these can usually be performed when you start, but we will contact you if they
are required more urgently.
ONLY HEALTHCARE WORKERS INVOLVED IN PATIENT CARE / PATIENT CONTACT / BODY FLUID
SAMPLE HANDLING COMPLETE THIS SECTION (INCLUDING LABORATORY WORKERS)
All Healthcare Workers
Have you ever had an allergic reaction to natural rubber latex? Yes No
Have you ever had chickenpox? Yes No
Can you provide documented evidence of immunity to measles and rubella? Yes No
Have you ever tested POSITIVE for HIV/AIDS? Yes No
Have you ever had or tested POSITIVE for Hepatitis B? Yes No
Have you ever had or tested POSITIVE for Hepatitis C? Yes No
Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE2006)
Have you lived continuously in the UK for the last 5 years? Yes No
If no, please list all of the countries that you have lived in over the last 5 years?
Have you had a BCG vaccination in relation to Tuberculosis?
Approx date of vaccination:
Do you have any of the following?
A cough which has lasted more than 3 weeks? Yes No
Unexplained weight loss? Yes No
Unexplained fever? Yes No
Have you had tuberculosis (TB) or been in recent contact with open TB? Yes No
If yes to any of the above, please give details below
Exposure Prone Procedures (EPP) are those procedures where the worker’s gloved hands may be in
contact with sharp instruments, needle tips or sharp tissue (e.g. spicules of bone or teeth) inside a
patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not
be completely visible at all times.
EPP staff include:
• All surgeons
• All F1 and F2 doctors
• Dental staff including dentists, hygienists and dental nurses
• Theatre staff
• A& E doctors and nursing staff
• Midwives
Renal dialysis poses additional risks to patients and employees in renal dialysis must show they are not infected

with Hepatitis B virus before they can work.
If you require additional screening because you will be working in a EPP or renal dialysis post, the relevant
result has to be from a UK Occupational Health Department or UK accredited laboratory and must show that
photographic identification was checked at the time.
Health clearance for EPP work cannot be given until these results have been received and processed by
the Occupational Health Team. IF YOU HAVE PREVIOUS BLOOD RESULTS AND/OR DOCUMENTED
EVIDENCE OF RELEVANT VACCINATIONS, PLEASE SUPPLY A COPY TO THE OCCUPATIONAL HEALTH
SERVICE (address at end of this form) AS SOON AS POSSIBLE.
IF RESULTS ARE NOT AVAILABLE, YOU WILL BE REQUIRED TO BE TESTED IN OCCUPATIONAL
HEALTH AND YOUR HEALTH CLEARANCE WILL BE DELAYED UNTIL THESE RESULTS ARE
PROCESSED. If you are required to attend Occupational Health for these blood tests, you will be asked
to show formal photographic ID i.e. valid driver’s licence, passport or NUH ID for this procedure. This is
to comply with the Department of Health’s standard for Identified Validated samples (IVS).
Will you be performing exposure prone procedures (EPP)? Yes No
Will you be working on a renal unit? Yes No
Healthcare workers who perform EPPs have a legal duty to inform the Occupational Health Team if they suspect
or know that they are carriers of HIV, hepatitis B or hepatitis C
Section 4:
Declaration for all applicants
I declare that all of the statements and information I have included in this questionnaire are true and accurate to the
best of my knowledge. I understand that making a false declaration may lead to disciplinary action including
dismissal.
I also give permission for a member of the Occupational Health team to communicate with my own General
Practitioner, or any other health professional, if further information is required, and for that GP or healthcare
professional to give details of my clinical condition or other relevant information to the Occupational Health team.
I understand that I will be contacted to obtain my fully informed consent before any report is requested and that under
the Access to Medical Reports Act 1988:
• I have the right to see the report before it is sent
• I am entitled to ask the GP to amend or modify information which I consider to be inaccurate
• I have 21 days from notification to seek access to the report
Signature of Applicant
Date
Please send evidence of immunisations and blood results with this questionnaire in the prepaid envelope for
confidential return to :
City Hospital Campus
Nottingham Occupational Health
Hucknall Road
Nottingham
NG5 1PB
Direct Dial: 0115 962 7657
Fax: 0115 962 8017
Queen’s Medical Centre Campus
Nottingham Occupational Health
Derby Road
Nottingham
NG7 2UH
Direct Dial: 0115 9709 268
Fax: 0115 9709 704
Minicom: 0115 962 7749