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 as we do not have the capacity to hold these longer than this.

This questionnaire must be completed by all visitors entering TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY premises for professional reasons without a contractual arrangement e.g. visiting medical personnel, clinical observation, and researchers.

All visitors must be sponsored by a senior TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY staff member. The sponsor is responsible for the visitor while they are at TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY and must ensure that the visitor complies with all health and safety requirements of TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY including infection prevention and control.

 

If you have any questions about this form, please email us:

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

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

 


  • Section A: Visitor's Details

  • Section B: Sponsor's Details

  • Section C: Visitors who will have patient contact to complete

    TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY expects you to be able to provide (if required for contact tracing) documentation of; Hepatitis B (AntiHBs >20 iu/L), Measles (2 x MMR vaccination record or serology report), Chickenpox (history of disease or 2 x vaccination record), and Pertussis (record of vaccination received in the past 10 years).

    TE WHATU ORA – CAPITAL, COAST AND HUTT VALLEY has an expectation that those wanting special staff status to carry out work in a clinical setting will be fully vaccinated for covid.

  • Section D: Declaration Statement

    Health and Safety and infection control is extremely important with the hospital setting. There is both a higher risk from you possibly exposing others to any infection that you carry and also a higher risk that you may be exposed to an infectious disease from others within the hospital.

    Because of this we require an undertaking from you that you will not enter the hospital environment for work purposes or as an observer if you are suffering a potentially contagious disease. The main routes of exposure to an infectious disease are having direct skin to skin contact with other people or via contaminated surfaces, or airborne spread from breathing contaminated air or droplet spread (e.g. coughing or sneezing).

    We therefore require you to agree to this statement that you will not enter the hospital if you have an infectious disease or any symptoms such as fever, cough, cold, skin infection, or skin condition that is causing significant skin flaking. You must also follow any Health and Safety or infection control requirements asked of you by TE WHATU ORA - CAPITAL, COAST AND HUTT VALLEY staff members. If you have any questions or are uncertain then please contact the Occupational Health Nurse for further discussion and advice.

Last updated 19 January 2023.