Pre-Employment Referral Request form | Alliance for Better Care

Referrer’s details

Name *

First

Last

Title *

Organisation name *

Organisation address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Contact number *

Contact e mail address *

Employee details

Name *

First

Last

Date of birth *

Job title *

Telephone number *

Home address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email address *

The manager must identify the risks relevant to the post which may require occupational health involvement. We have grouped these into 4 profiles, please review below.

Profile 1: Healthcare Workers (Direct Clinical Contact)

Examples of Roles:

Nurses
Doctors
Porters
Pharmacists
Housekeepers

Key Characteristics:

Direct clinical contact with patients

Potential exposure to:

Blood-borne infections
Tuberculosis (positive patients or specimens)
Pertussis
Biological pathogens in a laboratory or mortuary
Biological agents in groundwork or untreated water sources
May handle specific high-risk pathogens
Requirement to perform Control and Restraint procedures
Display Screen Equipment (DSE) User

Check for MMR. Chickenpox, DTP, HEP B and BCG screening

Profile 2: Undertaking Exposure Prone Procedures

Examples of Roles

Surgeons
Dentist
Dental Nurse

Key Characteristics:

Workers whose gloved hands may encounter sharp instruments or sharp tissues (e.g., bone or teeth).
Occurs inside a patient’s open cavity or wound.
Situations where hands or fingertips may not be completely visible at all times.

Profile 3: Patient-Facing Non-Clinical Roles

Examples of Roles:

Receptionists
Clinic Administrators
Patient Liaison Officers

Key Characteristics:

In-person interaction with patients and/or work in and around clinical areas
Social contact with patients
Possible exposure to blood-borne infections
Manual handling of animate (patients) and inanimate loads (>5 kg)
Display Screen Equipment (DSE) User

MMR and chickenpox clearance

Profile 4: Non-Patient-Facing Office-Based Roles

Examples of Roles:

Medical Secretaries
Finance Staff
IT Support
Administrative Staff

Key Characteristics:

No in-person patient interaction
No work in clinical environments
Manual handling of inanimate loads (>5 kg)
Display Screen Equipment (DSE) User

No Imms checking required.

Please select the relevant profile the job role falls into: *

Profile 1: Healthcare Workers (Direct Clinical Contact)
Profile 2: Undertaking Exposure Prone Procedures
Profile 3: Patient-Facing Non-Clinical Roles
Profile 4: Non-Patient-Facing Office-Based Roles

To the best of my knowledge, I have completed this form accurately based on the role the employee will be undertaking. I understand that if the duties of this role change, a reassessment of the employee’s occupational health will be required.

Please confirm that you have read and understand the above statement. *

I agree