Work Health Assessment form

for employees with patient or body fluid contact

G4S Churchill
Your answers to this questionnaire will be CONFIDENTIAL to the Centre for Occupational Health and
Wellbeing and will not be given to anyone else without your written permission. The purpose of the
questionnaire is to establish if you have any health problems that could affect your ability to undertake the
duties of the post you have been offered or that might place you at any risk in the workplace.
Recommendations may be made regarding adjustments or assistance to the workplace as a result of this
assessment to enable you to do the job. The Trust aims to promote and maintain the health & wellbeing of all
its employees. Before health clearance is given you may be contacted by the Centre for Occupational Health
and Wellbeing and may need to be seen by an Occupational Health advisor or Physician.

Please complete the questionnaire as possible, and complete this form in BLACK typeface and block capitals
Title Ms / Miss / Mrs / Mr / Dr / Prof Male M Female
Last name: Dos Santos De Jesus First name: Augusto
Previous names (if applicable):
Date of
Proposed Job
birth: 24-08-1991 Cleaner
Title:

Department: Churchi Manager if

Oxford Site
ll known:
Home Address: 456 Cowley Road

Post code: OX4 2DW Email address: [email protected]

Mobile: 07383994424 Tel home: 07436047633
Name of
Tel No of GP:
GP:

Address of
GP:

YES NO
Have you previously worked/trained at Oxford Radcliffe Hospitals NHS Trust/Nuffield
-
Orthopaedic Centre/Oxford Brookes University, School of Health Care Studies?
If the answer to the above question is Yes, do you consent to the Centre for
Occupational Health and Wellbeing accessing any Occupational Health records held by -
them

PREVIOUS EMPLOYMENT IN THE LAST 5 YEARS

Employer Nature of your work Start date Finish date

25-04-2020 11-12-2021

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 Please answer all the questions below as fully as possible. If you tick YES, please include full
details i.e. Diagnosis, dates, treatment, any ongoing problems and any follow up appointments
pending. If there is not sufficient space below for you to include all the information, please
attach a separate sheet.

Yes No Further Information

1. Do you have any illness/impairment/disability (physical -

or psychological) which may affect your work?
2. Have you ever had any illness/impairment/disability -
which may have been caused or made worse by your
work?

-
3. Are you having, or waiting for treatment or taking any
medication or investigations at present? If your answer is
yes, please provide further details of the condition,
treatment and dates.

-
4. Do you think you may need any adjustments or
assistance to help you to do the job?

Tuberculosis screening Yes No

Have you had a BCG vaccination to protect you against Tuberculosis? -
Have you lived continuously in the UK for the last 5 years?

If no, please list all of the countries that you have lived or worked in for longer than 3
months over the last 5 years -

Do you have any of the following? Yes No

A persistent cough which has lasted for more than 3 weeks? -
Unexplained weight loss? -
Night sweats or unexplained fever? -

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 Have you, or any close member of your family, had tuberculosis (TB) or been in recent
contact with open TB?
If Yes please give details: -

Have you had a chest X-ray in the last 12 months? -

Immunity and Immunisation Status: All Health Care Workers with Patient Contact are required to provide
information relating to their immunity to TB, Rubella, Measles, Varicella (Chickenpox), and Hepatitis B.

Please provide copies of official documentation, with this form, of all the following immunisations. The
records can usually be obtained from your General Practitioner (GP) and/or your Occupational Health
Department. This may reduce the need for you to have further injections and blood-tests.

Section A
Immunisation Date vaccinated Blood test result
Hepatitis B course (consists of 3 injections) 1.11-07-2021
2.05-09-2021
3.20-01-2022
Booster
MMR (Measles Mumps and Rubella). 1. Rubella:
2. Measles:
TB skin test (Heaf/Mantoux) Date: Result:
Have you ever had chicken pox? Yes/No
Chicken Pox immunisations 1.
2.
Diphtheria/Tetanus/Polio Primary course: Boosters:
Hepatitis A 1. 2.

DECLARATION
The information in this section is true and complete. I agree that any deliberate omission, falsification or
misrepresentation in the application form will be grounds for rejecting this application or subsequent
dismissal if employed by the organisation.
I give permission for a member of the Centre for Occupational Health and Wellbeing to communicate with my
own general practitioner, or any other health professional, if further information is required and for that GP or
healthcare professional to give details of my clinical condition or other relevant information to the OH
advisor/physician at the Centre for Occupational Health and Wellbeing at the Oxford Radcliffe Hospital NHS
Trust.
I understand that I shall be contacted to obtain my fully informed consent before any report is requested and
that under the Access to Medical Reports Act, 1988:

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 I have the right to see the report before it is sent.
 I am entitled to ask the doctor to amend or modify information which I consider is inaccurate.
 I have 21 days from notification to seek access to the report.

*I do wish to seek access to this report/I do not wish to seek access to this report
(Please delete as appropriate)

I agree to the above declaration please mark an x in the box YES

Date: Completed By:Augusto Sign or print name: AD
I understand that if any recommendations to my employer are necessary as a result of this the Centre for
Occupational Health and Wellbeing will discuss the recommendations with me before making them to my
employer.

*I give consent for the Centre for Occupational Health and Wellbeing to make recommendations to my
employer, without me having seen a written copy of the recommendations first.

OR

*I would like to see a written copy of any recommendations the Centre for Occupational Health and
Wellbeing may make to my employer before they are sent.

* delete one of the above statements before marking your agreement below.

I agree to the above declaration please mark an x in the box YES -

Date: Completed By:Augusto Sign or print name:AD

Please email this form and scanned copies of additional information required to
[email protected]
Alternatively, please print, sign and post the completed form and additional information to the centre
for Occupational Health, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU

Before submitting this form, please ensure you complete the check box:
Check COMPLETE (X)

I have completed this form and included my full name, job title, place of work and
-
contact details
I have attached copies of all my blood tests as requested in this form -
I have included full details and dates of all my immunisations -
I have completed the declaration above, placed a mark in the box and signed or
-
printed my name
I have answered all of the questions on the Work Health Assessment form
-

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If you have any questions with regard to this please do not hesitate to contact the work health
assessment unit for advice on 01865 223325. Incomplete forms will need to be returned to you
and will result in a delay in your appointment.

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