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

  • Section A: Personal Details

  • 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.

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  • 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.

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  • Section D: General Questions

  • 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.

Last updated 6 November 2023.