OCCUPATIONAL HEALTH QUESTIONNAIRE

PLEASE COMPLETE THIS FORM ON YOUR COMPUTER AND SAVE BEFORE PRINTING OCCUPATIONAL HEALTH QUESTIONNAIRE Please ensure you complete the highlighted sections of the Questionnaire (except where indicated as programme specific), and you have provided full details where required. Frequently Asked Questions are available at www.canterbury.ac.uk/student-health-service. If you have omitted any information after printing, please hand write on the paper. When the Questionnaire has been completed by your GP Surgery and you have signed sections D & E, please photocopy and send the original by recorded delivery in an A4 envelope to the Student Health Service (Student Health and Wellbeing), Canterbury Christ Church University, North Holmes Road, Canterbury, Kent, CT1 1QU or hand deliver to the i-zone. Should any of the mandatory fields not be fully completed, the Questionnaire will be returned to you via email for completion. Until any outstanding matters are addressed, you will be unable to commence your place at the University. IT IS IMPERATIVE THAT YOUR GP SURGERY COMPLETES SECTION B IN FULL. SURNAME DR/MR/MRS/MISS/MS/OTHER: FIRST NAME(S) PREVIOUS NAME(S) ADDRESS EMAIL TELEPHONE NUMBERS (HOME) (MOBILE) DATE OF BIRTH (DD/MM/YY) COUNTRY OF BIRTH (IF NOT IN THE UK) UNIVERSITY CAMPUS AGE DATE OF ENTRY TO UK (IF APPLICABLE) START DATE (MONTH/YEAR) PROFESSIONAL PROGRAMME FOR STUDENT HEALTH SERVICE USE ONLY SCREENED EMAILED QLv4 OH DOCTOR BLOODS/VACCS REQUIRED RETURNED TO COMPLETE DISABILTY CLEARED QLv4 HEALTH CHECK BLANK QLv4 OH UPDATED REQUIRED (TICK BOX) OTHER RETURNED TO STUDENT ADDITIONAL OFFICE NOTES FOR OCCUPATIONAL HEALTH PROVIDER USE ONLY CLEARED YES NO NOTES FINAL CLEARANCE YES NO ACTION DATE SIGNED GP REQUEST SENT GP REPORT RECEIVED SPECIALIST REQUEST SENT SPECIALIST REPORT RECEIVED Page 1 of 8

SECTION A - Self Declaration The questionnaire is NOT part of the selection process for your chosen programme, however the University has a duty of care to ensure students are cleared as fit for purpose (see below). The questionnaire must be completed in full, as this will assist in processing your occupational health clearance and help identify any additional support required, and manage potential risk. I believe that I am fully able to meet the specific demands that are expected of me whilst on the programme FITNESS FOR PURPOSE IF NO, PLEASE GIVE FULL DETAILS, TREATMENTS AND DATES If you answer YES to any of the questions below please ensure you provide full details of treatments and dates. DO YOU CURRENTLY HAVE OR HAVE YOU EVER HAD: (NO MATTER HOW MINOR OR HISTORICAL) Fits, faints, convulsions, epilepsy or other neurological problems? IF YES, PLEASE GIVE FULL DETAILS, TREATMENTS AND DATES Depression, anxiety, emotional or nervous troubles, psychiatric, psychological or mental health problems? Alcohol or drug-related problems? An attempted suicide, deliberate self-harm or an eating disorder of any kind? ME or Post-viral Fatigue Syndrome? Any long-term medical condition, such as heart disease, diabetes, neurological disease or other chronic condition? A rash or skin problems including eczema and dermatitis Any condition (such as arthritis, painful joints or muscles, back/neck pain or injury or spinal deformity) which may affect movement or manual handling etc. An allergy to medicines, chemicals or other substances (such as latex) PLEASE GIVE ADDITIONAL INFORMATION ON THE PAGE PROVIDED AT THE END OF THE QUESTIONNAIRE Page 2 of 8

I believe that my general health and lifestyle are compatible with the pursuit of my chosen profession GENERAL HEALTH AND LIFESTYLE IF NO, PLEASE GIVE FULL DETAILS IF YES, PLEASE GIVE FULL DETAILS I have had days absent from school/work in the last two years due to illness Number of days and reasons I have had to leave employment/college/university on the grounds of ill-health or for unsatisfactory attendance I currently use recreational drugs Substance(s) and frequency of use I am currently taking medication (ie injections, tablets, medicines) Name, description and dosage My weight is My height is ADDITIONAL SUPPORT IF NO PLEASE GIVE FULL DETAILS I am able to complete this programme without any special support arrangements or adjustments. DO YOU HAVE: Any disability which will require support in order to undertake your chosen programme of study (including placements) Any chronic illness which will impact upon your ability to undertake your programme of study (including placements) IF YES, PLEASE GIVE FULL DETAILS Any learning difficulty (eg dyslexia) for which you will require support in order to undertake your chosen programme of study. PLEASE GIVE ADDITIONAL INFORMATION ON THE PAGE PROVIDED AT THE END OF THE QUESTIONNAIRE Page 3 of 8

PLEASE ASK YOUR GP OR PRACTICE NURSE TO COMPLETE SECTION B. Some GPs make a charge for the completion of this section. The University will reimburse up to 10 for Health and Social Care students ONLY, with the exception of Social Work. Once fully registered a payment slip can be obtained from the i-zone. DO NOT ATTACH RECEIPTS TO THIS FORM AS THEY WILL BE REMOVED AND DESTROYED. SECTION B - Health Declaration by GP or Practice Nurse Does the person named above have history of any of the following: Bulimia, anorexia, eating disorder or self-harm; depression or anxiety states; obsessive compulsive disorder; any psychotic illness; any other psychiatric illness; drugs or solvent misuse; alcohol-related Illness; behavioural problems. Any significant physical or medical condition such as back problems, arthritis, skin conditions, cardio-vascular or respiratory conditions? Any other condition which might render them unfit for their chosen profession? YES NO IF YES PLEASE GIVE FULL DETAILS, TREATMENTS AND DATES GP SIGNATURE PRACTICE STAMP PRACTICE NURSE SIGNATURE DATE SECTION C Vaccinations etc. FOR HEALTH AND SOCIAL CARE STUDENTS ONLY (NOT EDUCATION & SOCIAL WORK). Your GP or Practice Nurse should ONLY to provide details if you have had any of the vaccinations or blood tests listed below. If you have not, you will receive the necessary vaccinations and/or blood tests during the Occupational Health Clearance Event. This will enable you to gain clearance for your programme and placements. Vaccine / Test Date Result Initials/signature of GP/ Practice Nurse Hepatitis B 1 st Hepatitis B 2 nd Hepatitis B 3 rd Hepatitis B blood test Miu/ml MMR/ Rubella MMR/ Rubella Rubella blood test result Detected / Not Detected BCG BBV results (Midwifery, Paramedic Science and ODP only): HIV HBsAg Hep C Varicella Page 4 of 8

SECTION D - Declaration by Candidate and Disclosure of Personal Information I declare that, to the best of my knowledge, the information given in this questionnaire is accurate and complete. I understand that failure to disclose information or giving false information may result in withdrawal of the offer of a place at the University or in the termination of my place on a programme. SIGNED: DATE: Any information supplied will be in strict confidence to the University s Student Health and Wellbeing Department and Occupational Health Provider and will only be discussed with other essential staff at the University with your express permission. THE RELEVANT STATEMENT I agree to personal information being disclosed to essential staff at the University only as required. I do not agree to personal information being disclosed to essential staff at the University only as required. SIGNED: DATE: SECTION E - Consent to Obtain Medical Report NOTE: ALL applicants MUST sign this section. If you have answered YES to any of the statements in Section A and/or your GP has declared anything in Section B, it is possible that the Occupational Health Doctors will require a report from your GP or Specialist. The report will help the Occupational Health Doctors make a decision as to whether you are fit for purpose or if you will need support with your studies. You have a right to see any report before it is sent to the Occupational Health Provider, and they will inform you in writing if a report has been sought and advise on any necessary action. In order to assess your fitness to undertake your programme it may be necessary to obtain additional information about your health. Before you sign below you should be aware that you have certain rights under the Access to Medical Reports Act 1988. In summary these rights are: 1. To withhold your consent for an application to be made to your GP or Specialist. 2. To request sight of a report before it is sent to us. You must arrange with your GP or Specialist to see a report within 21 days. You may also ask to see a copy of the report for up to 6 months after it is requested. 3. Ask the GP or Specialist to amend any part of the report that you feel is misleading or inaccurate. 4. To attach a written statement giving your views on its content should the GP or Specialist decline to amend any part of the report. 5. To withdraw your consent to the report being sent to the Occupational Health Provider. Please note: The GP or Specialist may withhold from you any section of the report if (s)he thinks you would be harmed by seeing it. THE RELEVANT STATEMENT I do agree to a medical report on my health being requested I do not agree to a medical report on my health being requested THE RELEVANT STATEMENT I do wish to see this report before it is provided I do not wish to see this report before it is provided I understand that a copy of this consent form will be sent to my GP or Specialist and that this copy shall have the validity of the original. SIGNED: NAME AND ADDRESS OF GP SURGERY DATE: NAME AND ADDRESS OF SPECIALIST(S) Page 5 of 8

PLEASE USE THIS PAGE TO GIVE ADDITIONAL INFORMATION Page 6 of 8

PLEASE KEEP THIS PAGE FOR INFORMATION ABOUT OCCUPATIONAL HEALTH CLEARANCE QUICK GUIDE AND CHECKLIST Students on professional programmes MUST have Occupational Health clearance in order to complete the registration process. Students who have not completed registration will not be able to receive any bursary payments and there WILL be delays in commencing any placements. If registration is not completed in a timely fashion, for whatever reason, students will be withdrawn from their programme. Programmes of Study Education - BA, PGCE and Teach First Health BA Social Work, MA Social Work Health - Adult Nursing, Occupational Therapy, Diagnostic Radiography, Mental Health, Child Nursing. Requirements for Occupational Health Clearance Health Questionnaire screening and clearance by OH Doctor Health Questionnaire screening and clearance by OH Doctor + Vaccination and Blood Test Evidence (ie official documentation from your GP etc) Health - Midwifery, Operating Department Practice and Paramedic Science Health Questionnaire screening and clearance by OH Doctor + Vaccination and Blood Test Evidence (ie official documentation from your GP etc) + additional blood screening Health Questionnaire Screening and Acceptance (All programmes) Please ensure you complete the following actions All relevant sections of the Occupational Health Questionnaire is completed in full (Section B completed by GP/Practice Nurse, with Practice Stamp) Sections D and E are signed and dated Photocopy the fully completed questionnaire for your own records Send the original Questionnaire to Student Health Service (Student Health and Wellbeing), Canterbury Christ Church University, North Holmes Road, Canterbury, Kent, CT1 1QU in an A4 envelope by Recorded Delivery or by hand via the i-zone, obtaining a tracking number. Occupational Health Questionnaires are screened by the Student Health Service If required the Occupational Health Questionnaire will be referred to the Occupational Health Doctor The Occupational Health Doctor may require further information and a report will be sought. When the report is received a decision will be made on your fitness for purpose. This can delay health clearance however the Occupational Health Provider will notify you if a report is being sought by post or email. Page 7 of 8

PLEASE KEEP THIS PAGE FOR INFORMATION ABOUT OCCUPATIONAL HEALTH CLEARANCE Vaccination and Blood Test Evidence (Health and Social Care with the exception of Social Work) All vaccinations and blood tests can be done via the University s Occupational Health Provider. 1. Hepatitis B Vaccination Course 1 st Hepatitis B vaccine you will be able to receive this course from the University s Occupational Health Provider at the time of occupational health clearance it is free of charge. 2nd Hepatitis B (1 month after the 1st vaccine) 3rd Hepatitis B (6 months after the 1st vaccine) Hepatitis B blood level test (anti HBs) due 8 weeks after the 3rd vaccine. [NB It is your own responsibility to keep a record of dates for the 2nd and 3rd Hepatitis B vaccinations and blood test] 2. Rubella Immunity You need evidence of having had 2 MMR or Rubella vaccinations; otherwise these will need to be given. OR You need evidence of a Rubella blood test (with a Positive or Detected result) 3. BCG Immunity You need evidence of a BCG vaccination OR A visible BCG scar (this will be checked by the University s Occupational Health Service) OR Evidence of a Mantoux or Heaf test (with a Positive result) Vaccination and Blood Test Evidence (Midwifery, ODP and Paramedic Science students only) 1. Chicken Pox (Varicella) Immunity Test 2. Hepatitis B (HBsAg) (with a Negative or NOT Detected result) 3. Hepatitis C (with a Negative or NOT Detected result) 4. HIV (with a Negative or NOT Detected result) 5. Rubella Blood Test (with a Positive or Detected result) PLEASE NOTE All vaccinations and blood tests can be done via the University s Occupational Health Service. Some Health and Social Care applicants may have had routine vaccinations already given by their GP. However, it is unlikely that your GP will give all of the vaccinations needed prior to coming to the University. If you have the vaccinations done through the University s Occupational Health Provider (for example, the course of Hepatitis B vaccinations) and then fail to attend any arranged appointments, you will become responsible for making any alternative vaccination arrangements yourself, and the University will not pay for these nor reimburse any costs you incur. Students who have not completed all the required vaccinations and do not have all necessary immunities, are responsible for advising the staff who supervise their placements, and their manager at the placement, as to their vaccination and immunity status so that there can be appropriate management of any health risks. This is VERY IMPORTANT. Loss of your Occupational Health Record Card will incur a charge of 10.00. Page 8 of 8