Occupational Health Service Pre-Employment Questionnaire

This form is for ABC staff. Please complete all sections as requested.

Personal Details

Surname *

First Names *

Former name (if applicable)

Title *

Gender *

Date of birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Home Telephone

Mobile Telephone *

UK National Insurance No *

Position applied for: *

Position based at *

Recruiting manager

Proposed start date

Hours

Hours per week

Please provide as much information as possible for any declared conditions.

The Equality Act 2010 protects disabled people – including those with long term health conditions, learning disabilities and so called "hidden" disabilities such as dyslexia. If you tell us that you have a disability we can make reasonable adjustments. Do you consider yourself to have a disability? *

Do you have any back problems or other musclo-skeletal problems which will cause difficulty with bending, lifting or standing for long periods? *

Do you have a history of anxiety, depression, psychiatric disorder, stress related problems, eating disorders, drug/alcohol misuse, self harm or overdose? *

Do you take any regular prescribed medication? *

Do you have any known allergies? *

Do you have any skin conditions, allergies to skin cleansing products, latex or other glove problems? *

Have you, at any time, experienced fits, faints or blackouts? *

Have you ever had a positive test for any blood borne virus that could be transmitted by a contamination incident, e.g. HIV, Hepatitis B, Hepatitis C? *

Do you have any other health conditions which may affect your work in any way? *

Have you worked abroad in the last year? *

Have you had contact with anyone in your family whilst they have had Tuberculosis (TB) *

Have you recently coughed up blood, had profuse night sweats, been diagnosed with TB or had unexplained weight loss? *

Have you ever had chicken pox? *

Have you ever had shingles? *

Will you have patient contact (either regular or irregular) or be working with clinical materials in your role?

Immunisation history:

In order to process your application we require a full immunisation history, along with evidence to support this. If you don’t already have this you can request a copy of your immunisation history from your GP. If you are not able to provide this evidence we will need to arrange blood work in order to check your antibody status and this could result in a delay to your application. Please upload your vaccination record here.

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