Capital and Coast District Health Board logo

Confidential Medical Information

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

For patient contact positions (includes clinical workers, ward administrators, orderlies).

Please complete ALL sections. 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
  • ­Chicken Pox - a declaration of a history of having had chicken pox OR blood test results OR proof of chicken pox immunisation
  • Measles - blood test results OR proof of x2 MMR immunisation
  • Pertussis- (whooping cough) - proof of your last immunisation
  • TB - Send any previous TB screening test results e.g. Mantoux, Quantiferon CXR results.

Failure to send the above may result in a delay in processing your Occupational Health clearance for employment

Note: For non-patient contact positions please complete the Health Declaration Non-Patient Contact Form

If you have any questions about this form, please email occupational.nurse@ccdhb.org.nz

  • Section A: Personal Details

  • Section B: Tuberculosis (TB)

  • 0/500 Words
  • 0/500 Words
  • 0/500 Words
  • Section C: Infection Control

    CCDHB screens staff for infectious diseases including chicken pox, measles and hepatitis B. If you do not have immunity vaccination is recommended – please discuss with Occupational Health.

    CCDHB 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.

  • 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.

  • 0/500 Words
  • Section E: General Questions

  • 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.

Last updated 31 May 2018.