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UCL HUMAN RESOURCES DIVISION
OCCUPATIONAL HEALTH SERVICE
OH SCREENING CERTIFICATE FOR NHS RESEARCH / STUDY
The immunity to infectious diseases of anyone with patient contact is important because of your
ability to transmit Measles, Rubella, Chickenpox and Tuberculosis to vulnerable groups. In view of
this, all staff and students that will have patient contact must provide documentary evidence of
immunity to the diseases identified below. Evidence of immunity includes a blood test indicating
immunity or documentary evidence of having received the vaccination.
IMPORTANT: Do not go into the hospital if you are suffering from any infectious disease (e.g.
tuberculosis, heavy colds, diarrhoea and vomiting, infected skin lesions or unexplained skin
rashes) as this could pose an infection control risk to patients. Report any body fluid exposures to
the local Occupational Health immediately.
TO BE COMPLETED BY RESEARCHER / STUDENT:
I consent to the information in this document being shared with relevant staff in the NHS for the
purposes of ensuring my suitability to conduct research or undertake a placement within the NHS.
In addition, I consent to the sharing of relevant health information between my employer and those
NHS organisations where I wish to undertake research or undertake a placement. The information
will be used to assess my suitability to conduct research or be on placement within the NHS.
Name: Forenames Surname
Address:
PIN No: PIN
DOB:DOB
Email:
Mobile:
Signed:
Date:
RETURN ALL COMPLETED DOCUMENTS TO:
UCL Occupational Health Service, Gower Street London WC1E 6BT Tel: +44 (0)20 7679 7724
Fax: +44 (0) 20 7209 0256 ohsadmin@ucl.ac.uk
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IMMUNISATION HISTORY
***NOT TO BE COMPLETED BY THE APPLICANT- GO TO PAGE 3***
FOR OFFICE USE ONLY (GP or OHS)
Hepatitis B vaccine (if requireda)
Date: (1)
Date: (2)
Date: (3)
Date: (booster)
Anti HBs
Date:
Result:
Mantouxc
Date:
Result:
BCG Scarc
Scar Seen: Yes / No
BCG (TB vaccination)
Date:
Polio / tetanus / diphtheria vaccine
Date:
Rubella (German measles) blood testb
Date:
Result:
Measles blood testb
Date:
Result:
Varicella (chickenpox)
Positive history of infection?
b
MMR
History1 ofDate:
chickenpox? Y / N
iu/l
Location:
Yes / No
If no, blood test?
MMR 2b Date:
NOTES:
IF THE VACCINATION HISTORY IS BEING COMPLETED BY YOUR GP PRACTICE PLEASE
ASK THEM TO COMPLETE THIS SECTION BELOW
Practice stamp or no.:
aThe
GP / PN Name:
Signed:
advisor will discuss your expected NHS duties with you and advise if hepatitis B vaccination is required.
bEither
TWO MMR vaccines should be documented OR documented results of positive antibody results indicating
immunity to further infection.
cEither
a Mantoux test result within the last five years OR a history of BCG vaccination (or scar inspection) must be
documented.
I confirm that a self-assessment questionnaire including physical conditions, psychological conditions and
current workplace adjustments has been undertaken to confirm that there are no health-related matters that
could affect the health and safety of the applicant or others within the NHS.
Name (OH advisor):
Signed:
Date:
RETURN ALL COMPLETED DOCUMENTS TO:
UCL Occupational Health Service, Gower Street London WC1E 6BT Tel: +44 (0)20 7679 7724
Fax: +44 (0) 20 7209 0256 ohsadmin@ucl.ac.uk
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WORK RELATED HEALTH HISTORY: (To be completed by researcher / student,)
I am a School of Pharmacy undergraduate undertaking placement in the NHS: 
I am UCL employee undertaking research work within the NHS: 
(Tick as appropriate)
1. Do you currently have any health
problems, including psychological
problems, or are you awaiting surgery?
YES / NO
2. Are you presently receiving and
prescribed medication, treatment or
therapy except contraception?
YES / NO
If YES, give details and dates:
3. Do you have any health condition caused YES / NO
or made worse by work or study?
4. Do you have any disability1 or other
health condition not mentioned above
that may require additional help or
support to perform the research activity
or placement?
If YES, give details and dates:
If YES, give details and dates:
If YES, give details and dates:
YES / NO
If NO please complete:
5. Have you lived continuously in the UK for
YES
/
NO
the past 5 years?
COUNTRY NAMEs & DATES
-
6. Have you ever lived with a family
member who has TB?
YES / NO
7. Have you ever worked in area where
there TB is present?
YES / NO
If YES, give details and dates:
If YES, give details and dates:
8. Have you ever received treatment for TB
If YES, give details and dates
YES/NO
If YES, give details and dates:
9. In the last three weeks have experienced
a persistent cough, coughing up blood, YES / NO
profuse night sweats, unexplained fever
or unexplained weight loss?
10. Have you any other health issues
that have not been mentioned above
which you would like to provide further
details?
If YES, give details and dates:
YES / NO
Equality Act 2010 You would be regarded as disabled if you have a medical condition that has lasted or is likely to
last for more than one year and is sufficient to impair normal day-to-day activities.
RETURN ALL COMPLETED DOCUMENTS TO:
UCL Occupational Health Service, Gower Street London WC1E 6BT Tel: +44 (0)20 7679 7724
Fax: +44 (0) 20 7209 0256 ohsadmin@ucl.ac.uk
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I declare that the information above is true to the best of my knowledge.
To determine if there is evidence of past or active tuberculosis I understand a blood test
may be required. If the outcome is positive then a prompt referral will be made by the
Occupational Health Department for specialist treatment.
I consent to a blood test for tuberculosis; I have been informed if the outcome is positive my
placement will delayed and my manager will be informed.
I consent for my chest x-ray result to be shared with the TB clinic if clinically indicated
Signed:
Name:
Date:
RETURN ALL COMPLETED DOCUMENTS TO:
UCL Occupational Health Service, Gower Street London WC1E 6BT Tel: +44 (0)20 7679 7724
Fax: +44 (0) 20 7209 0256 ohsadmin@ucl.ac.uk