OCCUPATIONAL HEALTH DEPARTMENT

Darent Valley Hospital, Darenth Wood Road, Dartford, Kent, DA2 8DA. Tel (01322) 428451

CONFIDENTIAL
PLEASE NOTE: Failure to fully complete this health declaration will result in it being returned to you and may delay your start date.

OHD 2009

Page 1 of 7

OCCUPATIONAL HEALTH DEPARTMENT

Darent Valley Hospital, Darenth Wood Road, Dartford, Kent, DA2 8DA. Tel (01322) 428451

PERSONAL DETAILS Surname: Shaukat Previous Surnames: Date of Birth: 26/12/1982 Male F e m a l e Current Address: 13 Aston Green, Hounslow. Post Code: TW4 7QG Tel: 02032500031 General Practitioner Mobile :07883426647 Dr .Sukhdev Matharu E-mail:sadafshaukat10@hotmail.com Tel: 02086301111 No no Sadaf Mr Miss Ms Dr (tick as appropriate)

NHS Number: 7020837

Have you ever been health screened for employment within the NHS? If YES give details of last post / location and date of leaving:

Not Will the post involve Exposure Prone Procedures (i.e. Surgical / Invasive procedures) Yes No S ur e

POST APPLIED FOR:

CLINICAL OBSERVER

Based at: DARENT VALLEY HOSPITAL EMPLOYING ORGANISATION: DARTFORD & GRAVESHAM NHS TRUST

Please send the clearance form to: HELEN SMITH, MEDICAL EDUCATION DEPARTMENT Tel: 01322 428100 ext. 6738 We are committed to a policy of equal opportunities and in particular recognise the duties specified in the Disability Discrimination Act. We seek to offer employment and volunteer opportunities appropriate to physical or mental disability when possible, as long as the disability does not compromise the health and safety of employees, other workers or patients. The questions that follow are asked to determine functional capacity and fitness for work and to assist in identifying reasonable adjustments to accommodate someone with a disability. The information in this form will be kept strictly confidential within the Occupational Health Service and will not be used or disclosed to any other person without the written consent of the person to whom the information relates. This completed form is a confidential document and should be placed in the addressed envelope provided, sealed and returned directly to the Occupational Health Department.

OHD 2009

Page 2 of 7

OCCUPATIONAL HEALTH DEPARTMENT

Darent Valley Hospital, Darenth Wood Road, Dartford, Kent, DA2 8DA. Tel (01322) 428451

For Occupational Health Service use only. From the information provided, this person appears FIT for Employment OHS to see: Yes No Prior to start date: Yes Yes Yes No No No

The above has attended for health screening and appears FIT for employment Signature: Date:

OHD 2009

Page 3 of 7

HEALTH / MEDICAL INFORMATION Please tick the appropriate Yes or No box for the following questions and give details as fully as you can. Useful details to include would be: When did the problem occur? Were you treated by your GP, seen in outpatients or admitted to hospital? Question 1 2 3 4 Do you have, or have you ever had, any medical conditions or operations? Are you receiving any pills, tablets, inhalers, injections or other treatment, at the moment? (including GP prescribed, herbal, self-medication, physiotherapy etc) Have you ever suffered a work-related illness, or given up work because of ill health? Have you ever had any physical limitation which might affect your ability to work? (including vision or hearing) If yes, have you had any workplace adjustments for this during previous employment? 5 Have you ever had any kind of back, joint or muscle problem? Did it lead to time off work? 6 Have you ever had: a. A skin problem? b. Any allergies? c. A persistent cough, unexplained weight loss or fever in the past 12 months? Have you ever had any mental illness which might affect your ability to work? (including anxiety, depression, self-harm, eating disorders, psychological or emotional problems) If yes, have you had any workplace adjustments for this during previous employment? 8 9 Have you ever had a drug or alcohol problem, which has affected your work? Have you returned from living or working abroad in the past year? How long did it last? Were unable to work or prevented from carrying out normal daily activities? Type of treatment received? Does the condition still affect you in any way?

No

Yes

Question

Additional Details I have had a caesarean section performed in 2008 for the birth of my son

OHD 2009

Page 4 of 7

NB: If any information is given falsely or has been deliberately omitted, you may be regarded as ineligible for employment or liable to be dismissed.

Height: metres 5 feet 3 inch 74 Kgs

Weight: st lb

IMMUNITY AND IMMUNISATION STATUS: All Health Care Workers with Patient Contact are required to provide information relating to their immunity to TB, MMR, chickenpox, and Hepatitis B. In addition, Doctors, Dentists, Nurses and Midwives undertaking exposure prone procedures (EPPs), are required to provide documented evidence of having undergone an identity validated blood test showing a Hepatitis B surface antigen status, Hepatitis C antibody and HIV antibody. This is for any EPP post commencing after May 2008 and is to comply with Department of Healths health clearance guidelines. If this information is not available, there may be a delay in the OH clearance and hence the date that you could join the Organisation. Your Consultant or Manager will be advised that you cannot commence EPP work until appropriate information has been received. If you are aware that you have any infectious disease or other health related condition that may impact upon your work, you have a responsibility to discuss these with the OHS. Definition of Exposure Prone Procedures: Those invasive procedures where there is a risk that injury to the worker may result in the exposure of the patients open tissue to the blood of the worker as a result there would be a risk to the patient if the worker was a carrier of Hepatitis B, Hepatitis C or HIV. Employees who may be involved in exposure prone procedures are: Medical staff in Surgical areas, Theatres, Accident and Emergency, Obstetrics and Gynaecology, limited anaesthetic tasks. This includes medical students and clinical attachments. Trained Nursing staff in the above areas. Midwives and student midwives. All Dentists and dental hygienists. Podiatry Surgeons All ambulance staff accepted for Paramedic training and those paramedics involved in pre-hospital trauma.

Identified Validated Samples are required for exposure prone procedure posts. The sample must be from an Occupational Health Service who has confirmed the identity of the person by checking photographic ID, this includes a passport, photographic driving licence or a photographic ID card. Laboratory reports: Please include copies of Laboratory results which must be, legible and from a UK accredited Laboratory for Hepatitis B, Hepatitis C and HIV. VACCINATION / DISEASE HISTORY

Have you had any of the following diseases? Please complete giving exact dates where possible. Measles
Yes No Date:

OHD 2009

Page 5 of 7

German Measles (Rubella)

Yes

No

Date:

Chicken Pox (Varicella)

Yes

No

Date December 2005

Hepatitis C

Yes

No

Date:

Tuberculosis

Yes

No

Date:

Have you received any of the following vaccinations or tests? Please complete giving exact dates where possible. Hepatitis B Vaccine Antibody Test: Date (1):1//02/2001 Yes No 5 yearly Booster Yes No Date: Date: 2 doses. Yes No Date (2):1/02/2001 Date (3):

How many doses of Hepatitis B vaccine have you had in total?

Are you known to have had a previous infection with Hepatitis B virus (had the disease)? Are you known to be a carrier of the disease? No Low High

Yes

infectivity?

Yes BCG Vaccine Measles Antibody German Measles Antibody MMR Vaccine DTP Vaccine Date (3): Chicken Pox (Varicella) Antibody Yes Yes Yes Yes Yes No No No No No Date: Date: Date: Date (1): Date (1):

Scar Present Result: Result: Date (2): Date (2): Date (5): Result:

Yes

No

Date (4): No Date:

These three questions must be completed by EPP workers only Hepatitis B Antigen
OHD 2009

Yes

No

Date:14/04/2010

Result: non reactive

Page 6 of 7

Hepatitis C Antibody HIV Antibody

DECLARATION

Yes Yes

No No

Date:27/03/2011 Date:09/03/2011

Result: non reactive Result: non reactive

I confirm that the information given on this form is correct to the best of my knowledge. I understand that if any information is false or has been deliberately omitted, I may be regarded as ineligible for employment or liable to be dismissed. I understand that medical details will not be divulged without my permission to any person outside Occupational Health Service, but an opinion about my fitness to work will be given to management. I agree that the Occupational Health Service can (please tick relevant boxes) 1. 2. 3. Obtain my Occupational Health record from any other NHS Organisation Obtain my immunisation and screening results from any other NHS Organisation Transfer my immunisation and screening results to other NHS organisations where I am working, where I intend to work, be on placement or part of a rotational training post. Date:28/02/2012

Signature: PRINT Name: Sadaf Shaukat

The Work of NHS Scotland: A Minimum Standard - Occupational Health Assessment for Pre-employment & Pre-placement (July 2008) is acknowledged. Parts of this questionnaire are based upon their work.

OHD 2009

Page 7 of 7