SCHOOL OF BIOLOGICAL SCIENCES
HEALTH SCREENING FORM
The University has a legal responsibility safely to manage all work, to provide a safe
and healthy workplace and to ensure that all systems of work are safe. Under certain
legislation it is legally obliged to monitor the health of persons working with potentially
hazardous materials. This form enables the University to fulfil its duties and to
ensure training has been received. No person is permitted to work with specified
potentially hazardous materials until they have received, or are receiving, adequate
training (whether in this University or elsewhere) and a Risk Assessment has been
completed.
Health surveillance is a requirement for all of the listed schemes of work. Unless a
correctly completed form is returned to Occupational Health, approval for your
registration and permission to work will not be given.
Ionising Radiation
Approved scheme(s) No(s)
_______
Chemical Hazards:
Carcinogen, Mutagen or Teratogen
Specific Substance(s) should be detailed overleaf
(go to Section 2)
Other special hazard
Specific Substance(s) should be detailed overleaf
(go to Section2)
Sensitisers:
Respiratory
Specific Substance(s) should be detailed overleaf
(go to Section 2)
Skin (R43/H317
Specific Substance(s) should be detailed overleaf
(go to Section 2)
Genetic Modification (GM)
Approved scheme(s) No(s)
Organism Hazard Group:
Containment level:
(go to Section 3)
_______
_______
_______
Biological Hazards
Approved scheme(s) No(s)
Organism Hazard Group:
Containment level:
_______
_______
_______
Microbiological hazards
Approved scheme(s) No(s)
Organism Group:
Containment level:
_______
_______
_______
(go to Section 3)
(go to Section 3)
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Worker Details:
Title (Mr/Mrs/Miss/Dr./Prof.)
_______
Surname (Family name)
_________________
Forename (Given name)
_________________
Date of Birth (dd/MM/yyyy)
_______
University e-mail address:
________________
Male or Female (M/F) _______
Position ___________________
(e.g. Research Officer, postgraduate, visitor etc.)
Location: Room/lab number(s) _______
Start date ___________ Finish date ____________
Supervisor’s name
…………………………………………………………………
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Section 2: Details of substances:
Continue on a separate sheet if necessary
Name
………………………………………………..
Date of Birth
………………………………………………..
Name of Substance
Nature of Hazard (1)Physical State (2)Amount (3)
Frequency &
Control Measures (5)
Duration of Use (4)
Date Exposure
Commenced
Date Exposure Incident Accident or
Ceased
Surveillance records attached (6,7)
(1) Carcinogen, mutagen, substance toxic to reproduction, respiratory sensitizer (i.e. asthmagens), skin sensitizer with relevant risk or hazard phases
where listed. Check for R45, R46, R60, R61, R64 or H334, H335, H336, H340, H341, H350, H351, H360, H361, H362, H370 to H373.
(2) Liquid, solid, dust, vapour or gas
(3) Include amount and units
(4) Daily, weekly, monthly, rarely
(5) Fume cupboard, laminar flow cabinet, local exhaust ventilation (LEV), glove box or other form of isolator, personal protective equipment (please
specify)
(6) Please attach copies of any incident/accident details
(7) Please keep with any health surveillance outcomes from OHS
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SECTION 3:
OCCUPATIONAL HEALTH SERVICE
UNIVERSITY OF ESSEX
HEALTH SCREENING RECORD
PRIVATE AND CONFIDENTIAL
This form is confidential to Occupational Health. Once completed, please
return to ohquery@essex.ac.uk or by post to Occupational Health Service,
Room 3.109, University of Essex, Wivenhoe Park, Colchester, Essex CO4
3SQ
All staff who will be involved in laboratory work with Hazard Group 2 or 3 pathogens, or
Class 2 or 3 genetically modified organisms, or human blood or tissue samples that may
contain Group 2 or 3 pathogens, must complete health screening before beginning this
work.
The aim is to identify anyone who may be at particular risk from infection, if exposed, in
order to advise on appropriate precautions to help mitigate this risk.
If an Occupational Health Advisor considers specific precautions or support measures
are required to ensure your safety, we will advise your manager of these, after discussion
with you. Information on any underlying health issue will not be divulged unless you
request this.
Whilst you continue in such work, you must inform the OH Service if:




You are involved in any incident where you may be accidentally exposed to the pathogen(s)
you work with
You develop symptoms that might be caused by exposed to the pathogen(s) you work with
You develop any health condition which may increase your risk of infection if exposed
You change your name or address
Data Protection information
The information that you supply on this questionnaire will be held in confidence by the
Occupational Health Service as part of your occupational health record. You can obtain
access to your record by contacting the Occupational Health Service on 01206 872399,
or contacting us at the email address above.
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Your details
Title:
Full name:
Department/Faculty/Section/School:
Date of birth:
Job title:
Contact telephone number:
Current residential address:
GP name, address and telephone number:
Project information
Name of Principle Investigator:
Project Reference Number (obtainable from the
Principle Investigator):
Will your work involve handling human pathogens?
Yes No
If “Yes”, please state the name of the pathogen(s):
Will your work involve handling genetically modified
organisms?
Yes No
If “Yes”, please state the name of the organism(s):
Will your work involve the handling of human blood,
serum or unfixed human tissue samples?
Yes No
Date work begins:
Intended duration:
Medical Information
Have you ever had any bone marrow disorder or any
form of cancer?
Yes No
Do you have sickle cell disease?
Have you had your spleen removed?
Yes No
Have you been treated with steroids in the past 18 months
Yes No
Do you have eczema, psoriasis or other skin disease?
Yes No
Do you have any chronic lung or heart disorder?
Yes No
Do you have any other health problems that may affect
your resistance to infection?
Yes No
Is there a history of immune-deficiency or susceptibility to
infection in your family?
Yes No
Yes No
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Do you take any medicines (including non-prescription
drugs) regularly?
Yes No
Have you ever had a fit or blackouts?
Do you wear contact lenses?
Are you prone to eye infections?
Yes No
Yes No
Yes No
Do you have any physical impairment that may affect
your ability to work safely in a laboratory
(e.g. restricted mobility, significant visual impairment,
impaired hearing, co-ordination or dexterity)?
(Women only) Are you pregnant or considering pregnancy
during the duration of this project?
Yes No
Yes No
If the answer is “Yes” to any of the above questions, please give details:
Vaccination History (answer only if relevant to your work):
For any work with human tissue or blood samples
Have you completed a Hepatitis B vaccination course
(3 doses)?
Yes No
If “Yes”, give dates:
Did you have a blood test to check response?
Yes No
If “Yes”, what was the result?
Have you had a booster does since completing your
original course?
Yes No
If “Yes”, give dates:
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Declaration
I have answered all questions to the best of my knowledge.
I agree to inform the Occupational Health Service of any significant
change in my health status whilst involved in work with risk of
exposure to infections agents
Signed: ______________________________________________
Date:
___________________________
Print name: __________________________________________
For OH use only
Date received: _____________________________
Notification: Fit / Review / Not Fit
(delete as applicable)
Signed: ________________________________________
Date:___________________________
Print name: ____________________________________
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