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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.


For non-patient contact positions please complete sections – A, D, E and F.


If you have any questions about this form, please email

  • 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 19 October 2017.