Occupational Health - Health Declaration for NZDF Personnel

Confidential Medical Information

Form to be returned to Occupational Health at least 2 weeks prior to start date

Please complete ALL sections. Please attach all previous occupational health screening results and immunisation records.

If you have any questions about this form, please email occupational.nurse@ccdhb.org.nz.

Section A: Personal Details
Name *
Previous name(s)
Date of birth *
Ethnicity *
Country of birth *
Gender *
Address *
NHI number (if known)
GP practice or name *
Home phone number
Mobile phone number *
Email address *
Do you consent to health information being sent to the above email address? *
Position to be undertaken within CCDHB *
Ward/department *
Start date *
NZDF Manager/Officer contact person *
Have you previously been employed by CCDHB? *
If yes, what year were you employed and what year did you resign?
Section B: General Questions
1. Skin Assessment - Have you ever had a skin condition? *
Have you ever suffered from eczema/dermatitis?
Have you ever suffered from psoriasis?
Do affected areas include hands, arms, face, neck or head?
Details
Is it currently active?
Details
Are you currently having treatment for this?
Details
2. Chicken pox - Have you ever had chicken pox? *
Have you ever been immunised against chicken pox or been tested for immunity?
3. Measles - Do you have a documented record of having had two MMR immunisations? *
If you do not have a immunisation record, have you had a blood test for immunity?
4. Hepatitis B - Have you been immunised against Hepatitis B? *
Have you been screened for Hepatitis B? *
5. Influenza - have you been immunised against influenza? *
Date of last immunisation
6. Pertussis (whooping cough) - have you been immunised against pertussis? *
Date of last immunisation
7. Country of birth *
8. How long have you lived in New Zealand (in years and months)? *
9. If you have worked in a healthcare setting outside of New Zealand in the last two years, please state countries and length of time worked in each 0/500 Words
10. Have you ever had a test for TB? (Quantiferon TB Gold or Mantoux) *
11. Have you had a recent chest x-ray related to TB screening or exposure? *
12. Have you had contact with TB without respiratory protection? *
13. Have you been part of a contact tracing exercise for TB? *
If you answered ‘Yes’, did you comply with all recommendations e.g. take prescribed medication or complete investigations?
14. Have you ever been diagnosed with TB or been given medication for TB? *
Details 0/500 Words
15. Do you have any medical condition or are you taking any medication which causes depression of your immune system e.g. renal failure, organ transplant, cancer, HIV or taking prednisone? *
Details 0/500 Words
16. Have you, in the last 2 years, experienced any of the following symptoms (lasting a month or more)? Tick all that apply.
Unexplained weight loss

Unexplained night sweats

Undiagnosed cough

Undiagnosed shortness of breath

Swellings under the arm or around the head/neck region
17. Do you have any health issues that may affect your work? *
Details: 0/500 Words
Section C: Privacy and Declaration Statement

Clinical employees are reminded to consider their own risk of infection with blood-borne pathogens (hepatitis B, hepatitis C and HIV) and the associated risk of transmitting infection to patients. Professional bodies (NZ Medical Association, NZNO, Australasian College of Surgeons etc.) have statements relating to this, and workers should acquaint themselves with the appropriate association policies. Any employee who is a carrier of a blood-borne disease and knowingly exposes their patients to a risk of infection based on their own risk assessment, without seeking further counselling, could be open to disciplinary proceedings.
I declare to the best of my knowledge that the information I have given in this questionnaire is correct. I understand that giving false or misleading information or suppressing information may be a reason for disciplinary action to be taken against me if I am employed by CCDHB.
I understand that the information related to health screening will be placed on my Occupational Health file. I have a right to access this information and to obtain copies of my test results.
I consent to information regarding infection prevention and control, e.g. proof of immunity to specific infectious diseases and vaccination history, being passed on to Hutt Valley and Wairarapa District Health Boards for the purposes of pre-employment screening if required.
I consent to information on my personal immunity status and immunisation to be made available to my manager and the CCDHB area/ward/department for the purposes of assisting with managing worker and patient safety, and for emergency planning and response purposes.
The information will be collected in accordance with the Privacy Act 1993 and the Health Information Privacy Code 1994. This declaration will be treated as a confidential medical record by CCDHB Health & Safety Service who will give recommendations to the relevant manager regarding fitness to work only. No medical details will be divulged to managers or any other employees in the organisation without the employee’s permission. If a workplace injury occurs in the future, insurers may, with the employee’s consent, request health information contained in this form to determine eligibility for cover.
The information will be used by CCDHB Health and Safety Service to identify and record the health status of personnel, fitness for work, identify reasonable workplace modification and provide a database for future occupational health issues.
While it is convenient to send information electronically and most of the information may not be highly sensitive, transmission of health information may not be secure and it is against CCDHB’s privacy policy to transmit personal or sensitive information via unsecured external email. Once an email leaves a server it can be routed across multiple servers, maybe in several countries before delivery to your mail server. It(s) is not known where the email will travel, whose servers it may cross or how long it will be stored on those servers. There is a risk that unless e-mail messages are encrypted, confidential information and attachments sent via e-mail could be intercepted, accessed and read by third parties. If you have ticked “yes” and consented for health information to be sent to your private email address this confirms you are aware of the risks outlined above and that, whilst being aware of the risks, you wish to continue to have your information conveyed to you via e-mail. This confirms your authorisation of correspondence via unsecured email.
I have read and understood the above declaration statement. *
Attach a file to this form. If you have more than 5 attachments, please email them to occupational.nurse@ccdhb.org.nz.
Attach a file.
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Last updated 8 February 2023.

Occupational Health - Health Declaration for NZDF Personnel

Confidential Medical Information

Form to be returned to Occupational Health at least 2 weeks prior to start date

Please complete ALL sections. Please attach all previous occupational health screening results and immunisation records.

Section A: Personal Details

Section B: General Questions

Section C: Privacy and Declaration Statement