Occupational Health - RMO Transfer Health Declaration

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 occupational.nurse@ccdhb.org.nz.

Section A: personal details
Name *
Previous name(s)
Date of birth *
Ethnicity *
Country of birth *
Gender *
Address *
NHI number (if known)
GP practice or name *
Home phone number
Mobile phone number *
Email address *
Do you consent to health information being sent to the above email address? *
Position offered *
Ward/department *
Start date *
Manager *
Have you previously been employed by CCDHB? *
If yes, what year were you employed and what year did you resign?
Section B: general questions
1. Skin Assessment - Have you ever had a skin condition? *
Have you ever suffered from eczema/dermatitis?
Have you ever suffered from psoriasis?
Do affected areas include hands, arms, face, neck or head?
Details
Is it currently active?
Details
Are you currently having treatment for this?
Details
2. Since your last pre-employment screening at CCDHB, have you been exposed to infectious tuberculosis (TB) without respiratory protection? *
Details 0/500 Words
If you answered ‘Yes’, were you followed up through the TB contact tracing process?
3. Are you being monitored following a blood/body fluid exposure? *
Details 0/500 Words
4. Since your last pre-employment screening at CCDHB, have you had any new physical or psychological health issues that may affect your work? *
Details 0/500 Words
5. If you have an existing health issue has anything changed since your last pre-employment screening? *
Details 0/500 Words
6. CCDHB has a smoke-free policy which prohibits workers and visitors from smoking anywhere in its facilities or grounds. If you smoke and would like assistance to quit, the Smoking Cessation Programme is available through Occupational Health or QUITLINE 0800 778 778. I would like occupational health to contact me to discuss the smoking cessation programme. *
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.
I declare to the best of my knowledge that the information I have given in this questionnaire is correct. I understand that giving false or misleading information or suppressing information may be a reason for disciplinary action to be taken against me if I am employed by CCDHB.
I understand that the information related to health screening will be placed on my Occupational Health file. I have a right to access this information and to obtain copies of my test results.
I consent to information regarding infection prevention and control, e.g. proof of immunity to specific infectious diseases and vaccination history, being passed on to Hutt Valley and Wairarapa District Health Boards for the purposes of pre-employment screening if required.
I consent to information on my personal immunity status and immunisation to be made available to my manager for the purposes of assisting with managing worker and patient safety, and for emergency planning and response purposes.
The information will be collected in accordance with the Privacy Act 1993 and the Health Information Privacy Code 1994. This declaration will be treated as a confidential medical record by CCDHB Health & Safety Service who will give recommendations to the relevant manager regarding fitness to work only. No medical details will be divulged to managers or any other employees in the organisation without the employee’s permission. If a workplace injury occurs in the future, insurers may, with the employee’s consent, request health information contained in this form to determine eligibility for cover.
The information will be used by CCDHB Health and Safety Service to identify and record the health status of personnel, fitness for work, identify reasonable workplace modification and provide a database for future occupational health issues.
While it is convenient to send information electronically and most of the information may not be highly sensitive, transmission of health information may not be secure and it is against CCDHB’s privacy policy to transmit personal or sensitive information via unsecured external email. Once an email leaves a server it can be routed across multiple servers, maybe in several countries before delivery to your mail server. It(s) is not known where the email will travel, whose servers it may cross or how long it will be stored on those servers. There is a risk that unless e-mail messages are encrypted, confidential information and attachments sent via e-mail could be intercepted, accessed and read by third parties. If you have ticked “yes” and consented for health information to be sent to your private email address this confirms you are aware of the risks outlined above and that, whilst being aware of the risks, you wish to continue to have your information conveyed to you via e-mail. This confirms your authorisation of correspondence via unsecured email.
I have read and understood the above declaration statement. *
Attach a file to this form. If you have more than 2 attachments, please email them to occupational.nurse@ccdhb.org.nz.
Attach a file.
Attach a file.

Last updated 8 February 2023.

Occupational Health - RMO Transfer Health Declaration

Confidential medical information

Section A: personal details

Section B: general questions

Section C: Privacy and Declaration Statement