New Starter Clinical Form

Please enable JavaScript in your browser to complete this form.

Proof of Immunity (Please send the following)

Varicella	You must provide a written statement to confirm that you have had chickenpox or shingles; however, we strongly advise that you provide a serology test result showing varicella immunity.
Tuberculosis	We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare).
Rubella, Measles & Mumps	Certificate of two MMR vaccinations or proof of a positive antibody for Rubella and Measles.
Hepatitis B	Recent pathology report showing titre levels of 100 IU/L or above.
Hepatitis B Surface Antigen (EPP Only)	Hepatitis B Surface Antigen test (Inc. 'e' antigen and DNA viral loads, IVS).
Hepatitis C	Hepatitis C antibody test (Inc. Hepatitis C RNA/PCR, IVS).
HIV	HIV I & II antibody test (Inc. DNA viral loads, IVS).

Proof of Immunity (Please send the following) EPP Candidates Only

Hepatitis B Surface Antigen	Evidence of Hepatitis B Surface Antigen Test (Inc. ‘e’ antigen and DNA viral loads if applicable Report must be an identified validated sample. (IVS)
Hepatitis C	Evidence of a Hepatitis C antibody test (Inc. Hepatitis C RNA/PCR if applicable) Reports must be an identified validated sample. (IVS)
HIV	Evidence of a HIV I and II antibody test (Inc. DNA viral loads if applicable) Reports must be an identified validated sample.(IVS)

Exposure Prone Procedures

Will your role involve Exposure Prone Procedures

UK General Data Protection Regulation (UK GDPR)

All information supplied by you will be held in confidence by Healthier Business UK Ltd. Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. Your data may also be cross referenced should you have registered with other clients of Healthier Business UK Ltd. Your personal data may be required to be seen by an occupational health advisor or physician; however it will not be shown, nor their contents shared with anyone - including Managers, Human Resources Advisors, GP’s, Specialists or third party’s - without your explicit consent. You have the right of erasure (the right to be forgotten), refusal of consent and withdrawal of consent without detriment (withdrawal of consent can be exercised at any stage of the process). The only exceptions to this may be a court order for release of records in a judicial dispute or where there is a public responsibility obligation. Further information regarding your rights under GDPR can be found on the following: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation- gdpr/individual-rights/ If you wish to have sight of our privacy policy, please send your request to support@hbcompliance.co.uk

Consent

Consent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed. You have the right to withdraw your consent at any stage of the process, either verbally or in writing. Further information regarding consent is available on the ‘Candidate Screening Leaflet'.

All staff groups complete this section

Do you consent to this questionnaire and your immunisation reports being assessed by an Occupational Health Advisor for the purpose of providing a Fitness to Work Certificate?

Do you consent to our Occupational Health Advisors speaking with you regarding any declaration you may have made relating to your medical history?

Do you consent to our Occupational Health Advisors making recommendations to your employer/agency to assist with your ability to carry out your prospective role?

Declaration

I will inform my employment agency if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

Name

Date

Signature

Clear Signature