Pre-Employment Health Declaration - Non-Patient Contact Positions

Confidential Medical Information

Form to be returned to Occupational Health at least 2 weeks prior to start date, but do not submit more than 2 months prior to your start date as we do not have the capacity to hold this.

For Category B: Non-patient Contact/Non-clinical positions

Please complete ALL sections. Please attach all relevant information or records, including Covid-19 immunisation record.

These results will be required as evidence according to the responses in the following questions. Failure to send the above may result in a delay in processing your Occupational Health clearance for employment.

Note: For Category A: Patient Contact/Public Contact positions (includes Clinical Workers, Ward Administrators, Orderlies) please complete the Health Declaration Patient Contact Form.

If you have any questions about this form, please email RES-PreEmpScreening@ccdhb.org.nz

Section A: Personal Details
First names *
Surname *
Previous name(s)
Date of birth *
Ethnicity *
Country of birth *
Gender *
Address *
Mobile phone number *
Personal email address *
NHI number (if known)
GP practice or name *
Do you consent to health information being sent to the above email address? *
Position offered *
Ward/department *
Hospital base (eg Wellington, Hutt, Kenepuru) *
Start date *
Manager *
Have you previously been employed by CCDHB or HVDHB? *
If yes, what year were you employed and what year did you resign?
Section B: Infection Control

TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY screens staff for Covid-19 immunity; Covid Vaccination is an expectation for all clinical roles.
Measles - Do you have a documented record of having had two MMR immunisations? *
If you do not have an MMR immunisation record, have you had a blood test for immunity? *
Please provide your MMR immunisation record or immunity blood test result.
Influenza - Have you been immunised against Influenza? *
What was the date of your last Influenza immunisation? *
Pertussis (whooping cough) - Have you been immunised against Pertussis? *
What was the date of your last Pertussis immunisation? *
COVID-19 - Have you been vaccinated for COVID-19? *
Date of 1st primary COVID-19 dose: *
Date of 2nd primary COVID-19 dose: *
Do you have evidence of having had a COVID-19 infection? If so, when? 0/500 Words
Attach your COVID-19 immunisation record
Section C: Musculoskeletal

The position you have applied for may require you to perform tasks involving the following:
moving patients or objects, prolonged standing or sitting, pushing, pulling, reaching, bending, computer use, restraint of patients/clients or repetitive tasks.
1. Have you ever had a sprain or strain (back, neck, shoulder or arm) which has affected your ability to work for more than five days? *
2. Have you ever had any discomfort, pain or injury (back, neck, shoulder, arm or hand) which built up over time due to repetitive physical activity? *
3. Do you have any other musculoskeletal conditions (back, shoulders, legs, feet) that may affect your ability to work? *
If you answered yes to any of the above 3 questions, please give details including date, cause and diagnosis, ACC claims, time off work, and any residual problems: 0/500 Words
Section D: General Questions
1. Hearing - Do you have any hearing difficulties? *
If you answered ‘Yes’ please provide details
Have you previously worked in a noisy environment? *
Have you ever had a hearing test? *
2. Vision - Do you wear corrective lenses? *
Do you have any vision difficulties aside from wearing glasses/corrective lenses? *
If you answered ‘Yes’ please provide details
3. Mental Health condition - In the last 5 years have you had a mental health problem, such as a diagnosed psychiatric or psychological condition, that required either: more than 1 week off work, treatment such as medication or counselling for more than 3 months, or hospitalization? *
If you answered ‘Yes’ Occupational health will make contact with you to discuss further. Please provide details.
4. Allergies or Sensitivities - Do you have any allergies or sensitivities? *
What is your allergy/ sensitivity to?
5. Do you have any health issues that may affect your work? *
Details:
6. Do you require any workplace modifications? *
Details
6. TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY has a smoke-free policy which prohibits workers and visitors from smoking anywhere in its facilities or grounds. If you smoke and would like assistance to quit, the Smoking Cessation Programme is available through Occupational Health or QUITLINE 0800 778 778. Smoking cessation - I would like occupational health to contact me to discuss the smoking cessation programme (please select) *
Section E: Privacy and Declaration Statement

The pre-employment health assessment forms part of a screening process designed to ensure that all new staff are fit to perform the duties and tasks of the job they have been offered.

The information collected during the assessment will be appropriate to the area in which employment is offered. Your future manager has indicated which hazards and potential risks you may be exposed to and appropriate screening will be carried out accordingly.
In the event that you have any medical or health related condition(s) that are:

• likely to affect or limit your ability to carry out the full requirements of the position you have been provisionally offered; or
• that may be aggravated by the tasks of that position; and/or
• you are certified as being “unfit for work” by a registered medical practitioner during a pre-employment assessment

You accept that TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY may elect to withdraw the offer of employment or terminate your employment (where the offer has already been accepted by you), unless the position can be reasonably altered or the workplace modified in order to reduce the risk of harm or injury to yourself or others.

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, and 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 TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY.
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 on my personal immunity status and immunisation to be made available to my manager 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 TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY Health & Safety Service who will give recommendations to the relevant manager regarding fitness to work only. No medical details (excluding immunity/immunisation status in the above paragraph) 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 TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY 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 TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY’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. *

Last updated 6 November 2023.

Pre-Employment Health Declaration - Non-Patient Contact Positions

Confidential Medical Information

Section A: Personal Details

Section B: Infection Control

Section C: Musculoskeletal

Section D: General Questions

Section E: Privacy and Declaration Statement