Warwick Medical School Assessment
CONFIDENTIAL FOR OCCUPATIONAL HEALTH USE ONLY
University Hospitals Coventry and Warwick Occupational Health have been contracted by the University of Warwick
Medical School to provide Occupational Health services for Warwick Medical School staff undertaking research
activities or clinical work. The purpose of this assessment is to help determine if you require any vaccinations,
immunisations or tests to protect your or another’s persons health or if you require any adjustments or assistance to
be able to undertake you work safely.
Before health clearance is given you may be contacted by University Hospitals Coventry and Warwick Occupational
Health for further clarification and may need to be seen by an Occupational Health Advisor and/or Physician.
Appropriate advice, in general terms, will be provided to Human Resources at Warwick Medical School.
TITLE
SURNAME
DATE OF BIRTH
FORENAMES
STAFF NUMBER
MALE
FEMALE
HOME ADDRESS
EMAIL:
HOME Tel:
MOBILE Tel:
Please answer either question below.
1. I am not aware of any health conditions or disability which may impair my ability
to undertake effectively the duties of the position which I have been offered
OR
2. I do have a health condition or disability which may affect my work and which
may require special adjustments to my work or at my place of work
YES
NO
YES
NO
If you have answered YES to the second question you will be contacted by a member of the Occupational Health
Department from University Hospitals Coventry and Warwick Occupational Health.
JOB TITLE
Please provide a brief description of proposed Research Activities/Clinical Work
Location of proposed research
During your research activity/clinical work will you be involved in any of the following:
1.
Direct contact with patients/service users and direct involvement in patient care?
YES
NO
2.
Non-clinical social contact with patients/service users but not directly involved in
patient care (e.g. interview studies)?
YES
NO
3.
Working in a laboratory and handling pathogens or potentially infected specimens?
YES
NO
4.
Will you be undertaking Exposure Prone Procedures*? (see over for description)
YES
NO
5.
Will you be at risk of exposure to blood-borne viruses?
YES
NO
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Immunisation History
1. Have you been employed in the NHS previously? If YES
please give the name of your previous employer below
2.
Have you lived or worked, including elective placement, in a high prevalence TB area for
six months or more within the previous 12 months?
YES
NO
YES
NO
3. Have you ever been vaccinated or immunised against any of the following?
If YES please give details or provide documentary evidence if available. If exact dates are not known please give year.
Vaccination
Received
Tuberculosis (BCG)
YES
NO
Rubella (German
Measles)
YES
NO
Hepatitis B
YES
NO
YES
NO
YES
NO
MMR (Measles,
Mumps, Rubella)
Varicella Zoster
(Chicken pox)
Childhood or First
Course Dates
4.
Have you ever had Chicken pox or Shingles (please specify)?
5.
Have you had blood tests for any of the following?
INFECTION
TESTED
Other Dates
YES
Comments
NO
DON’T KNOW
DATE OF TEST
RESULT
Immune
YES
NO
Hepatitis B antibody
YES
NO
Hepatitis C antibody
YES
NO
Detected
YES
NO
HIV antibody
YES
NO
Detected
YES
NO
YES
NO
Detected
YES
NO
YES
NO
Detected
YES
NO
YES
NO
Detected
YES
NO
Rubella
antibodies
(German Measles)
Measles antibody
Chicken Pox antibodies
Titre Level if known
NOTE: Only UK accredited laboratory reports or a validated UK Occupational Health Service Immunisation report
or certificate will be accepted as evidence if the post involves Exposure Prone Procedures.*
*Exposure Prone Procedures are those invasive procedures where there is a risk that injury to the worker may result
in exposure of the patient’s open tissues to the blood of the worker. These include procedures where the worker’s
gloved hands may be in contact with sharp instruments, needle tips and sharp tissues (e.g. spicules of bone or teeth)
inside a patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be
completely visible at all times.
I AGREE to attend University Hospitals Coventry and Warwick Occupational Health when requested to discuss having
immunisations, tests and for any other issues that arise relating to my ability to safely carry out my work.
I CONSENT to University Hospitals Coventry and Warwick Occupational Health consulting my General Practitioner,
Consultant, other Occupational Health Services or any other Health Services and authorize them to reply to
enquiries solely relating to any vaccinations, immunisations or immunity checks that I have undergone.
Signed: ..................................................................................... Date: .......................
FULL NAME (Block Capitals please) ...................................................................................................
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