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:

Capital & Coast Hospitals: RES-OccupationalNurs@ccdhb.org.nz    

Hutt Valley Hospital: RES-WorkplaceOHS@huttvalleydhb.org.nz

 

 

  • Section A: Personal Details

  • 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).

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  • 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.


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  • 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.

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  • Section E: General Questions

  • 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.

Last updated 19 January 2023.