Genetic Manipulation Health Form - Heriot-Watt University

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Genetic Manipulation Health Form - Heriot-Watt University

APPENDIX IHERIOT-WATT UNIVERSITYIN MEDICAL CONFIDENCEGENETIC MANIPULATIONHEALTH RECORD FORMFORM IInformation to be recorded in full on, or as soon as possible after, entering employment and/orbeginning work involving genetic manipulation (GM).1. PERSONAL DETAILSSURNAME:SURNAME AT BIRTH:FORENAMES:STATUS: Undergraduate/Postgraduate/Staff/Visitor (delete as appropriate)SEX:DATE OF BIRTH:PERMANENT ADDRESS:NATIONAL INSURANCE NUMBER:DATE OF COMMENCEMENT OF PRESENT POSITION:DATE OF COMMENCEMENT OF GM WORK:PREVIOUS PERIODS OF EMPLOYMENT WITH THE UNIVERSITY:NATURE OF WORK:2. PREVIOUS EMPLOYMENTPlease give details of previous employment (including studentships, fellowships, etc.), giving names of employers,place of work, approximate dates and nature of work.Name of employerAddress(place of work)Period of employmentNature of work08/01


2. PREVIOUS EMPLOYMENT (cont.)Has work involving genetic manipulation been carried out in the past in any laboratory other than the present placeof work? Yes/No (delete as appropriate)If Yes, please give details:3. PAST MEDICAL HISTORY4. IMMUNISATION HISTORY5. RADIATION EXPOSURE(a) medical(b) occupational6. FAMILY PRACTITIONERName:Address:Telephone number:SMO to sign :Date:Please return this form to the University Health Service at Riccarton.08/01

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