Occupational Health - Internal Transfer Health Declaration

Confidential medical information

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

All staff transferring within the TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY please complete entire form. Unless you are moving from a Non-patient facing position to a patient facing position a full health declaration form is required – please contact Occupational Health if you have questions about where to find this.

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 *
Mobile phone number *
Email address *
NHI number (if known)
GP practice or name *
Do you consent to health information being sent to the above email address? *
Ward/department transferring from *
Hospital Base transferring from (e.g. Wellington, Hutt, Kenepuru) *
Position *
New Ward/department transferring to *
New Position *
Hospital Base transferring to (e.g. Wellington, Hutt, Kenepuru) *
Start date *
Manager *
Section B: tuberculosis (TB)

Low-risk 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. Since commencing work at CCDHB/HVDHB, have you been exposed to infectious tuberculosis (TB) without respiratory protection? *
Details 0/500 Words
If you answered ‘yes’, were you followed up through the TB contact tracing process?
Have you in the past 5 years had any travel which resulted in you spending 6 weeks or more in a high-risk country (any country NOT listed above)? *
If 'Yes' please list which countries and how long you spent in each. 0/500 Words
When were you last in a high-risk country?
Did you work in a healthcare setting in any country not listed above? Please state countries and length of time worked in each. 0/500 Words
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 an expectation of the hospital primarily for those working in clinical areas, but also some staff working in non-clinical areas. Please discuss your vaccination history or concerns with Occupational Health.
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? *
2. Chickenpox - Have you ever had Chickenpox? *
3. Hepatitis B - Have you been immunised against Hepatitis B *
4. Pertussis (whooping cough) - Have you been immunised against Pertussis? *
Date of last pertussis immunisation
5. 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 – Since commencing work at CCDHB/HVDHB have you been exposed to high levels of noise without wearing hearing protection? *
Details
Have you previously worked in a noisy environment? *
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 answer ‘Yes’ Occupational health will make contact with you to discuss further. *
4. Allergies or Sensitivities – Do you have any allergies or sensitivities? *
If so, what is your allergy/sensitivity to?
5. Health issues - Do you have any health issues that may affect your work? *
If you answered ‘Yes’ please provide details.
Do you require any workplace modifications? *
If you answered ‘Yes’ please provide 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

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 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 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.

Occupational Health - Internal Transfer Health Declaration

Confidential medical information

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