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Confidential medical information

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

To use this form you must have previously completed a full Occupational Health pre-employment screening at CCDHB.

If you have any questions about this form, please email

  • Section A: personal details

  • Section B: general questions

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  • Section C: 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 24 May 2018.