| Surrey and Sussex Healthcare NHS Trust

Answers to this questionnaire are confidential to the Occupational Health Department and will not be disclosed to anyone else without your permission. The purpose of the questionnaire is to identify the need for any adjustments/accommodations within the workplace and so it is important that you give full details of any health concerns/physical limitations in order that appropriate advice can be given to assist with your wellbeing at work. It will also identify any immunisation needs / baseline health surveillance required for your post.

You will be required to upload your proof of immunisations before submitting your form.

This health assessment form will be stored securely and will only be accessible to the Occupational Health Team.

Please complete each field as much as possible. If you do not know the information required, please leave blank.

If known

Site

East Surrey Hospital

Crawley Hospital

Horsham Hospital

Please select the site(s) where you will be based

Hours

Please select from the drop-down menu

This will be the name of the coordinator that has emailed or written to you

Personal details - to be completed by all staff

Title

Gender

Male Female

Date of birth

Please use the following format: dd-mm-yyyy

Are you new to working for the NHS?

Yes No

Have you ever worked / trained at Surrey and Sussex Healthcare NHS Trust?

Yes No

Previous employment in the last 5 years (please complete fully)

Start date

Please use the following format: dd-mm-yyyy

Finish date

Please use the following format: dd-mm-yyyy

Start date

Please use the following format: dd-mm-yyyy

Finish date

Please use the following format: dd-mm-yyyy

Start date

Please use the following format: dd-mm-yyyy

Finish date

Please use the following format: dd-mm-yyyy

Start date

Please use the following format: dd-mm-yyyy

Finish date

Please use the following format: dd-mm-yyyy

Section 3

Have you ever tested POSITIVE for HIV / AIDS?

Yes No

Have you ever tested POSITIVE for Hepatitis B?

Yes No

Have you ever tested POSITIVE for Hepatitis C?

Yes No

HEALTHCARE WORKERS WHO PERFORM EPPs HAVE A LEGAL DUTY TO INFORM OCCUPATIONAL HEALTH (IN CONFIDENCE) IF THEY SUSPECT OR KNOW THAT THEY ARE CARRIERS OF HIV, HEPATITIS B OR HEPATITIS C.

Section 5

DECLARATION - to be completed by ALL staff

In submitting this form, I declare that all information provided is true and accurate to the best of my knowledge and belief. I accept that, if it is subsequently found that medical information has not been disclosed by me or has been misleading or false, the Trust may terminate my employment. I understand and accept that I may be required to attend the Occupational Health Department for a health assessment. I understand that Occupational Health may need to obtain further medical information from my GP / Specialist / previous occupational health provider, if required and that I will be contacted to obtain my fully informed consent before any report is requested. I understand that, if any recommendations to my employer are necessary as a result of this Work Health Assessment, the Occupational Health department will discuss the recommendations with me before making them to my employer.I confirm that I have read and understand the declaration.

Please tick the box below to confirm you have read and understand the declaration below.

Please select one of the below statements before submitting this form.

I give consent for the Occupational Health Department to make recommendations to my employer without me having seen a written copy of the recommendations first.

I would like to see a written copy of any recommendations the Occupational Health Department may make to my employer before they are sent to my employer.

ALL NEW STAFF ARE INVITED TO DISCUSS WITH OCCUPATIONAL HEALTH ANY CONCERNS THEY MAY HAVE ABOUT THEIR HEALTH AND WORK

Would you like an appointment with an Occupational Health Advisor prior to commencing your post?

Yes No

Please enter your full name to complete this form

Upload vaccination history document

If you have been unable to upload your immunisation record then please email it separately to ssx-tr.sashoccupationalhealth@nhs.net, clearly stating your full name and that your attached documents are immunisation details.

Upload any other associated documents

I have read and accept the terms & conditions.

I accept

Lane Fox REMEO Occupational Health New Starter Assessment Form

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