Confidential Medical Information

If you have any questions about this form, please email

Form to be received by Occupational Health at least two weeks prior to start date

This questionnaire must be completed by all visitors entering CCDHB premises for professional reasons without a contractual arrangement e.g. visiting medical personnel, clinical observation, researchers.

All visitors must be sponsored by a senior CCDHB staff member. The sponsor is responsible for the visitor while they are at CCDHB and must ensure that the visitor complies with all health and safety requirements of CCDHB including infection prevention and control.

Section A: Visitor's Details

  • Section B: Sponsor's Details

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

  • Declaration Statement

Last updated 4 July 2022.