Pre-Employment Health Declaration - 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.

For Category A: Patient Contact/Public Contact positions (includes Clinical Workers, Ward Administrators, Orderlies).

Please complete ALL sections in the form below. Please attach all previous occupational health screening results and immunisation records.

Immunisation record / previous blood test results:

Some of these at least would have been done as pre-course screening e.g. Medicine, Nursing, Allied Health so should be available from your GP, Student Health or Occupational Health services of previous employers.

Hepatitis B - blood test results including both antibody level and surface antigen and any Hepatitis B immunisation records
Chickenpox - a declaration of a history of having had chicken pox OR blood test results OR proof of Chickenpox immunisation
Measles - blood test results OR proof of x2 MMR immunisation
Pertussis- (whooping cough) - proof of your last immunisation
COVID-19 – For overseas applicants please provide proof of vaccination
TB - Send any previous TB screening test results e.g. Quantiferon, CXR results

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.

For Category B: Non-patient Contact/Non-clinical positions please complete the Health Declaration Non-Patient Contact Form

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

Section A: Personal Details
First names *
Surname *
Previous name(s)
Date of birth *
Ethnicity *
Country of birth *
Gender *
Address *
Are you currently living in New Zealand? *
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 HVDBH? *
If yes, what year were you employed and what year did you resign?
Section B: Tuberculosis (TB)

Low prevalence countries - Australia, Austria, Belgium, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Holland, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, New Zealand, Norway, Slovakia, Sweden, Switzerland, the UK, and US).
1. Were you born and have you resided in a low prevalence country? *
2. How long have you lived in New Zealand (in years and months)? *
3. Have you in the past 5 years spent 6 weeks or more in a high risk country i.e. a country not listed above? *
If you answered 'Yes' which country/countries and for how long? 0/500 Words
When did you leave the last high-risk country?
4. Did you work in a healthcare setting in any country NOT listed above? If so, please state countries and length of time worked in each. 0/500 Words
5. Have you ever had a test for TB? (Quantiferon TB Gold?) *
If you answered ‘Yes’, what was the result? 0/250 Words
6. Have you had a recent chest x-ray related to TB screening or exposure? *
If you answered ‘Yes’, when was the most recent test and what was the result? 0/250 Words
7. Have you had contact with TB without respiratory protection? *
8. Have you been part of a contact tracing exercise for TB? *
If you answered ‘Yes’, when was the contact tracing and did you comply with all recommendations e.g. complete investigations or take prescribed medication? 0/500 Words
9. Have you ever been diagnosed with TB or been given medication for TB? *
If you answered ‘Yes’ please provide details of diagnosis and/or treatment. 0/500 Words
10. 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? *
If you answered ‘Yes’ please provide details. 0/500 Words
11. 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
Section C: Infection Control

TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY screens staff for infectious diseases including chicken pox, measles and hepatitis B. Please note that vaccination is expected in order to provide immunity, particularly for clinical roles. Please discuss your vaccination history or concerns with Occupational Health if you do not have immunity the listed disease processes.

TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY must know the hepatitis B status of clinical staff. This is important for the protection of patients, and workers in the event of future claims.
1. 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?
Please provide your MMR immunisation record or immunity blood test result.
2. Chicken pox - Have you ever had chicken pox? *
Do you have evidence of having been immunized against chicken pox or having been tested for immunity? *
Please provide your Chickenpox immunisation record or immunity blood test result.
3. Hepatitis B - Have you been immunised against Hepatitis B? *
Have you been screened for Hepatitis B? *
4. Influenza - have you been immunised against influenza? *
Date of last influenza immunisation
5. Pertussis (whooping cough) - have you been immunised against pertussis? *
Date of last pertussis immunisation
6. COVID-19 – have you been vaccinated for Covid-19? *
Date of Covid-19 immunisations
Please provide your COVID-19 vaccination record.
7. Do you have evidence of having had a COVID-19 infection? If so when? 0/500 Words
8. Mask fit testing - Have you been mask fit tested in the last 2 years? *
Please attach your mask fit testing certificate and name of mask type assessed.
9. Skin Assessment - Have you ever had a desquamating skin condition such as eczema, dermatitis, psoriasis? *
If you answered ‘Yes’ please provide details
Do affected areas include hands, arms, face, neck or head?
Is it currently active (inflamed, flaking, broken skin)?
Are you currently having treatment for this?
If you answered ‘Yes’ please provide details
Section D: 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 E: 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’ please provide details. Occupational health will make contact with you to discuss further.
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:
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. *
Section F: 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 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 31 July 2024.

Pre-Employment Health Declaration - 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.

Section A: Personal Details

Section B: Tuberculosis (TB)

Section C: Infection Control

Section D: Musculoskeletal

Section E: General Questions

Section F: Privacy and Declaration Statement