Occupational Health - Special Staff Status Health Declaration

Confidential Medical Information

Who can apply for Special Staff Status (SSS)?

Special staff status health declaration is the process for authorising a person (who is not an employee or contractor) to be able to undertake work, education, observation, research or related activities within the Health New Zealand (HNZ) - Capital, Coast, Hutt Valley and Wairarapa district. This is done once a formal agreement by HR and the relevant department (this is your sponsor, and you must have one to complete an application) has been agreed to.

There are two parts to a Special Staff Status Health declaration clearance. It starts with approaching the relevant service manager and HR. Following this, Occupational Health assesses your health aspects to ensure you are not placed in a health risk position whilst on site and that others are not placed in a health risk position because of your clearance. This is a health and safety legislated requirement for all employers.

Once Occupational Health has processed your health clearance, we will provide this to you and your sponsor (via an email). A copy of this needs to be provided to HR along with your Application and Agreement for Special Staff status form (HR form), your sponsor will do this.

Examples of Special Staff Status approvals are: visiting/observing Medical Consultants, Students on Clinical Electives, School Students, Researchers, those on Work experience and Non-Clinical visitors and volunteers

Note: A SSS application is not needed were there are specific access or a MOU agreement already in place such as those for Nursing Students, Allied Health Students and Medical Students.

Next Steps are:

The below SSS Health declaration form must be returned to Occupational Health at least 2 weeks prior to the date you are requesting to visit but no more than 2 months before your planned visit, as a health clearance must be current. Then your sponsor must ensure the steps below are followed:

A sponsor must be an employee in a leadership role and be in a position to assign SSS role to a service. For example, a Senior Clinician or manager. This sponsor will need to:

Notify the SSS applicant in writing of the outcome of their application including:

i. The relevant details of your special staff status clearance,

ii. Time frames the clearance is valid for

iii. Specific activities you are cleared for.

iv. Provide you with a copy of the Code of Conduct

v. Assist you to complete the Security Identification process which you will need before you can commence.

vi. Be responsible for the supervision of conduct and activities during the period of SSS, including monitoring your compliance with all Health and Safety requirements of HNZ; including infection prevention and control.

vii. Ensure the SSS applicant practices within clearly defined parameters and that utilization of resources involved in the SSS are adequately controlled to monitor any costs incurred.

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

Section A: Visitor's Details
First names *
Surname *
Date of birth *
Gender
Mobile phone number *
Personal email address *
NHI number (if known)
Purpose of visit *
Purpose of visit (describe in detail the activities/duties to be undertaken) *
Start date *
Finish date *
Please note SSS can be awarded for a period of up to 12 months maximum, extension will require an annual renewal of their application. Occupational Health will make this contact near your anniversary.
Section B: Sponsor's Details
HNZ Capital, Coast, Hutt Valley, Wairarapa Sponsor’s (Department Manager) name *
Sponsor’s position *
Sponsor’s phone number *
Hospital Base (eg Wellington, Hutt, Kenepuru)
Section C: Visitors who will have patient contact to complete

As an approved SSS applicant/visitor working in a clinical setting, you will be required to provide, if requested, for contact tracing purposes, documentation of the following listed vaccinations.
There is an expectation that you will have completed these courses prior to seeking SSS health clearance.
• Hepatitis B (AntiHBs >10 iu/L),
• Measles (2 x MMR vaccination record or serology report),
• Chickenpox (history of disease or 2 x vaccination record),
• Whooping cough/Pertussis (record of vaccination received in the past 10 years).
Do you regularly have patient contact in other healthcare settings? *
Have you kept up to date with your occupational health screening requirements for infectious diseases, including Tuberculosis, Hepatitis B, Measles, Whooping cough and Chickenpox? *
Do you consent to your Covid-19 immunisation records being viewed for the purpose of this clearance? *
Section D: Declaration Statement

Health and Safety and infection control is extremely important with the hospital setting. There is both a higher risk from you possibly exposing others to any infection that you may carry and a higher risk that you may be exposed to an infectious disease from others within the hospital.
Because of this, we require an undertaking from you that you will not enter the hospital environment for work purposes or as an observer if you are suffering a potentially contagious disease. The main routes of exposure to an infectious disease are having direct skin to skin contact with other people or via contaminated surfaces, or airborne spread from breathing contaminated air or droplet spread (e.g. coughing or sneezing).
We therefore require you to agree to this statement that you will not enter the hospital if you have an infectious disease or any symptoms such as fever, cough, cold, skin infection, or skin condition that is causing significant skin flaking. You must also follow any Health and Safety, or infection control requirements asked of you by HNZ - Capital, Coast, Hutt Valley and Wairarapa district staff members.
If you have any questions or are uncertain then please contact the Occupational Health Nurse for further discussion and advice.
I have read the above statement and I agree to abide by the requirement not to enter the hospital with any infectious disease or symptoms as listed above *

Last updated 13 December 2024.

Occupational Health - Special Staff Status Health Declaration

Confidential Medical Information

Section A: Visitor's Details

Section B: Sponsor's Details

Section C: Visitors who will have patient contact to complete

Section D: Declaration Statement