Bedford Hospital Occupational Health and Wellbeing Services

Bedford Hospital Occupational Health and Wellbeing Services Please read carefully before completing this document. The purpose of this questionnaire is to ensure you are well enough for the proposed job and to advise your manager if you have a medical condition or disability which may require additional help or support in order to undertake the duties of the post you have been offered or place you or others at any risk in the workplace. Our aim is to promote and maintain the health of all people at work. You need to complete all the sections of this document and provide all your evidence where necessary. All healthcare workers must provide evidence of the past immunisation history i.e. date of their vaccines and blood reports. Failure to do so may result in this questionnaire being returned to you or delay your starting date. This questionnaire must be completed in BLACK pen / typeface and block capitals. Section 1 (Personal Information) Title: Ms / Miss / Mrs / Mr / Dr : Male Female Surname: Previous names (if applicable): Proposed Job Title: First name(s): Date of birth: Proposed Job: Department: Permanent Temporary Bank Home Address: Post code: Mobile: Email: Have you worked here before? Tel home: Have you ever worked for the NHS before? Last employer details: Last job title: How many days off work have you had due to sickness absence in the last 2 years? Section 2 (Health Declaration) Please tick or as appropriate to the statements set out below. Guidance notes are on pages 4 and 5. If you answer to either 1 or 2 then you will be contacted by the Occupational Health department for further discussion. It may be necessary for you to attend Occupational Health prior to commencing employment. 1. Are you aware of any health conditions or disability which might impair your ability to undertake effectively the duties of the position which you have been offered? 2. I do have a health condition or disability which might affect my work and which might require special adjustments to my work or at my place of work? Bedford Occupational Health and Wellbeing Services August 2014 Page 1

Have you ever tested POSITIVE for HIV/AIDS? Have you ever had or tested POSITIVE for Hepatitis B? Have you ever had or tested POSITIVE for Hepatitis C? Will you be performing exposure prone procedures (EPP)? (see below) Healthcare workers who perform EPPs have a legal duty to inform the OHS team if they suspect or know that they are carriers of HIV, hepatitis B or hepatitis C. 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 (including FY1 and FY2 doctors with a rotation into one of the EPP areas), dental staff, theatre staff, midwives, A&E doctors and A&E nurses. If you are unsure about your EPP status, please contact the OHS Team on 01234 792123 EPP staff MUST provide documentary evidence of hepatitis B status i.e. a satisfactory immunity status (antibody level >100) and non-infectivity status (surface antigen negative). Documentary evidence of hepatitis C and HIV status is also required for staff undertaking EPPs for the first time in the NHS. These must be an identified validated sample (IVS). Health clearance for EPP work cannot be given until these results have been received and processed by the OHS team. IF YOU HAVE PREVIOUS BLOOD RESULTS AND / OR DOCUMENTED EVIDENCE OF RELEVANT VACCINATIONS PLEASE SUPPLY A COPY WHEN YOU SUBMIT THIS FORM. IF RESULTS ARE NOT AVAILABLE YOU WILL BE TESTED IN THIS DEPARTMENT AND HEALTH CLEARANCE FOR EPP WORK WILL BE DELAYED UNTIL THESE RESULTS ARE PROCESSED. You will be asked to show formal photographic ID i.e. valid photographic driver s licence, passport or Bedford Hospital ID for this procedure. This is to comply with the Department of Health s standard for Identified Validated samples (IVS). Section 3 (Tuberculosis Screening) Tuberculosis (TB) screening is in line with Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006) 1. Have you lived continuously in the UK for the last 5 years? If, in which countries did you live in the last 5 years? 2. Have you travelled outside the UK recently staying longer than 2 months If, please states which country/ countries? 3. Have you had a BCG vaccination in relation to Tuberculosis? Approx date of vaccination: 4. Do you have a BCG scar? 5. Have you ever had Tuberculosis or treatment for Tuberculosis? 6. Have you been in recent contact with open TB? 7. Do you have any of the following: (a) A cough which has lasted for more than 3 weeks? (b) Unexplained weight loss? (c) Unexplained fever / heavy sweating at night? Bedford Occupational Health and Wellbeing Services August 2014 Page 2

Section 4 (Skin Assessment) 1. Do you currently have skin problems that may be linked to your clinical work? If which part/ parts of your body is being affected? 2. Are you aware of the possible causes of your skin problem? If please give details: 4. Have you been formally diagnosed with a skin condition which is linked to your work? If you can, please provide evidence either from your G.P., Occupational Health or the department where the diagnosis has been made. Applicants may be invited to attend Occupational Health for further skin assessment after they take on their post with the Trust. Section 5 (Immunisation History) All applicants need to provide evidence of their past immunisation history i.e. vaccination date and blood reports. Failure to do so may delay in their clearance and start date. Section 6 (Declaration) I declare that the information provided by me in this entire form is true and complete to the best of my knowledge. I understand that any deliberate omission, falsification or misrepresentation in this record may result, once employed, in disciplinary action by my employer, or the withdrawal of an offer of employment prior to commencement of employment. I give consent for the OHS to make recommendations to my employer, without me having seen a written copy of the recommendations first. OR I would like to see a written copy of any recommendations the OHS may make to my employer before they are sent to my employer. Print Name: Signature: Date: Once completed and please return to: Occupational Health and Wellbeing Services Bedford Hospital NHS Trust Kempston Road Bedford MK42 9DJ Tel: 01234 792123 Fax (safe Haven) 01234 795893 Occupational.health@bedfordhospital.nhs.uk Bedford Occupational Health and Wellbeing Services August 2014 Page 3

Guidance tes Applicants only: This document is for information only. Successful Applicants: Please read the information below carefully. You will be asked to confirm whether or not you need any work place adjustments to support you in your job role. If you are unsure about any of the information below, you may contact the occupational health (OH) department on 01234 792123 and ask to speak to one of the OH advisers. You may also contact your recruiting manager if you are unsure about any aspect of your job/role or workplace. If necessary someone from OH will contact you and take a history. Any medical or personal information that you provide to OH will be held in confidence and in accordance with the Data Protection Act (1998). It will only disclosed to a third party with your consent. Health problem Impact on work Adjustments/support Musculoskeletal problems (back, neck, joints etc) Mental health problems Skin conditions i.e. eczema, dermatitis, allergies, psoriasis Diabetes, epilepsy, heart conditions or any other condition that may be affected by working shifts. Allergies Dyslexia Sensory problems i.e. hearing, sight (not corrected by spectacles, lenses or hearing aids) Working in a hospital generally involves physical activity of some kind i.e. walking, standing, running (in an emergency), pushing, pulling, carrying loads, helping patients to move and transfer and working with computers (Display Screen Equipment (DSE)). Please check your job description to see how much physical activity your job entails. Working in healthcare can be busy and pressurised at times. Starting a new job or being newly qualified can add additional pressures. Existing mental health conditions such as depression and anxiety can be exacerbated when moving to a new job or environment. Working in healthcare, especially those working directly with patients or blood/body fluids, involves hand washing with soap and gels and wearing gloves. This may exacerbate existing skin conditions. Working with broken skin on your hands is an infection control risk. Some roles in healthcare require staff to work shifts (including nights). This may have an impact on some health conditions. Healthcare staff may be exposed to substances that cause or exacerbate existing allergies. Working in healthcare involves record keeping, calculating drug doses, reading complex medical information and processing complex information (at times under pressure). Some healthcare roles are more easily adapted for those with sensory deficits than others. There may be health and safety considerations i.e. fire safety, access. Most musculoskeletal problems are minor and resolve with or without treatment. Some chronic problems may require adjustments if mobility, strength, function or flexibility is impaired. If you require adjustments to your work due to musculoskeletal problems, these can be arranged as long as they are reasonably practicable. Support is available from the staff physiotherapist, the moving and handling team and the health and safety advisers. Support is available from the OHD and your manager. Please declare all mental health problems (including work related stress). You will be contacted by an OH adviser for a confidential discussion. Adjustments may be recommended Those with a pre existing skin problem require skin surveillance and may need adjustments. Alternatives to most products can be found to accommodate skin problems/complaints. Temporary adjustments may be made for those with broken skin on their hands. Those with suspected allergies may be referred for allergy testing. If you have a health condition that may be adversely affected by working nights, an assessment will be undertaken by the OH Team. Temporary or permanent adjustments may be required. Please declare all health conditions that may be affected by shift work especially night duty.. Please declare all allergies that may have an impact in the work place i.e. latex, chemicals, biological substances etc. Adjustments can be made to avoid substances and for replacements to be recommended. Those with dyslexia will be contacted by the OH team to discuss the impact that their dyslexia may have on their work. They may be asked to provide an educational psychologist s report to ensure that appropriate adjustments can be recommended (where necessary). An assessment will be undertaken in regard to any sensory deficit that may impact on the safety of staff or patients. It may be necessary to involve the access to work team if significant adjustments are required. Bedford Occupational Health and Wellbeing Services August 2014 Page 4

Health problem Impact on work Adjustments/support Blood borne viruses All surgeons, Dentists, Dental nurses, dental hygienists, medical staff in A&E, Urology, General practice, Obs and Gynae, midwives, qualified theatre staff (inc ODP, ODA) require clearance to practice exposure prone procedures (EPP) BEFORE they start work. Infectious diseases TB Any other health condition that may impact on your role (please see job description) New or expectant mothers. Sickness absence records Health care workers are sometimes exposed to infectious diseases such as TB, measles, chickenpox, rubella. The trust also has a duty to protect patients from catching infectious diseases from staff. You must tick option 2, if you are currently suffering from an infectious disease. You must tell occupational health BEFORE you commence work if you: By ticking option 1, you are confirming that you are symptom free. Some health conditions may be exacerbated by working in a health care environment or impact on your ability to perform all of your duties. Whilst not a health problem, new or expectant mothers have a legal right to a work place risk assessment. This will ensure that you are not exposed to hazards in the work place that may pose a risk to you or your unborn child. The trust will be asking your referee about your sickness absence record over the last 2 years. These staff groups will be sent a questionnaire requesting information on their Hepatitis B status. Those new to EPP need to provide information on their hepatitis C and HIV status as well. All health care workers who are infected with a blood born virus have a legal and ethical duty to inform OH in strictest confidence. Adjustments for EPP workers may be required All health care staff must bring details of their immunisations and blood test results to the occupational health department on their first day of work. The OH team will assess whether or not further vaccinations or blood tests are required to protect the health care worker and the patient. If you have a condition that lowers your immunity to infections (inc. HIV), you must inform OH so that adjustments can be made Have a cough that has lasted more than 3 weeks Have lost weight (not as part of a weight loss programme) Are coughing up blood Have night time sweats Have a fever associated with the above symptoms. You may discuss any health condition that you think may affect your work, in confidence, with the occupational health team. Where practicable, adjustments will be made to help you achieve your full potential in the workplace. Specific health conditions are not discussed with your manager or any other third party without your consent. You should inform your manager in writing that you are pregnant. On receipt of this information, your manager will undertake a risk assessment. If any risks/hazards are identified, adjustments will be made to minimise/remove them. This may or may not include the OH department. If you would like confidential advice in regard to work and pregnancy, you may self refer to OH. If your sickness absence record gives your recruiting manager cause for concern or if your absence hits one of the trigger points in the BHT sickness and absence policy, a member of the OH team will contact you. This is to establish if there is an underlying health condition and if the trust needs to make any reasonable adjustments for you. Bedford Occupational Health and Wellbeing Services August 2014 Page 5