CONFIDENTIAL to
King’s College Hospital Occupational Health & Wellbeing Department
Pre-Commencement Health Questionnaire
This form is to be completed by the prospective student and the completed form returned directly
to the Occupational Health & Wellbeing (OH&W) Department. In order to complete the form you
will need your offer letter and access to the programme spreadsheet located here:
http://www.kcl.ac.uk/aboutkings/orgstructure/ps/safety/docs/pgohreq.pdf.
1. Programme details
Programme:
Department:
Programme Code:
Faculty:
Programme Start Date:
(mm/yyyy)
Programme duration:
(yrs)
2. Your details
Student number (7 digit number on your offer letter):
Family Name (Block letters)
First Names
Date of Birth
Mr
Mrs
Ms
Dr
Professor
Miss
Other
Home Address*
Telephone number
Email address
Mobile number*
Name & address of
your General
Practitioner (GP)*
*If your home or GP address changes please inform Occupational Health so that they can amend their
records
Have you worked for, or studied at, King’s College London previously?
Yes
No
Yes
No
If yes, please give details
Do you have a contract (or honorary contract) with a hospital Trust?*
If yes, please give details:
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CONFIDENTIAL to
King’s College Hospital Occupational Health & Wellbeing Department
3. Health Questions
The information you provide is entirely confidential to the Occupational Health & Wellbeing Department and will
not be disclosed without your consent.
Please answer only those sections relevant to your proposed study activities (refer to the programme
spreadsheet and the Appendix for further assistance). Read and answer the questions carefully and to the best
of your knowledge (if you have any queries please contact your programme leader or Occupational Health as
appropriate).
If you have a disability but have not informed the university this prior to this point you may also wish to contact
disability@kcl.ac.uk for further advice and support.
3a: Health Condition
N/A
Please let us know if you have a disability or health condition that may benefit from Occupational Health advice
to enable you to complete your studies:
3b Laboratory-based studies
N/A
Please consult http://www.kcl.ac.uk/aboutkings/orgstructure/ps/safety/docs/pgohreq.pdf to see if you are
required to complete this section (Green columns).
Are you going to work with respiratory sensitisers?
If “Yes” do you suffer from any allergies?
Yes
/ No
Yes
/ No
Yes
/ No
Yes
/ No
Yes
/ No
Yes
No
Yes
No
Yes
/ No
Yes
/ No
If “Yes” please provide details:
Are going to work with human blood and/or tissue products?
If “Yes”, have you had a Hepatitis B vaccination?
If “Yes” please provide an approximate date:
(mm/yyyy)
Are you going to collect and/or work with soil or water samples?
If you have answered “Yes” have you had:
A tetanus vaccination?
If “Yes” please provide approximate date:
A hepatitis A vaccination?
If “Yes” please provide approximate date:
(mm/yyyy)
(mm/yyyy)
Are you going to work with microbiological or genetically modified agents?
If “Yes”, do you have a health condition, or are you taking medication, that may
increase your susceptibility to infection?
,
If you have answered “Yes”, please provide further information:
Pre-Commencement Health Questionnaire
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3c Clinical Contact with Patients
N/A
Please consult http://www.kcl.ac.uk/aboutkings/orgstructure/ps/safety/docs/pgohreq.pdf to see if you
are required to complete this section (Pink or Orange columns).
All candidates who will study in, or access, clinical areas please complete this section:
To assist with this process please attach any documentary evidence of vaccinations or immunity status
Have you been vaccinated against:
Measles
Mumps
Rubella
Chickenpox
Yes
Yes
Yes
Yes
/ No
/ No
/ No
/ No
If Yes, please provide approximate date:
If Yes, please provide approximate date
If Yes, please provide approximate date
If Yes, please provide approximate date
Have you lived continuously in the UK for the last 5 years?
(mm/yyyy)
(mm/yyyy)
(mm/yyyy)
(mm/yyyy)
Yes
/ No
A cough lasting more than 3 weeks
Yes
/ No
Unexplained weight loss
Yes
/ No
Unexplained fever
Have you ever had tuberculosis or been in close contact (family member or shared
a home) with some who has had tuberculosis?
Yes
Yes
/ No
/ No
Have you had a BCG vaccination against tuberculosis?
Yes
/ No
If no, please list the countries you have lived in over the last 5 years
(please attach additional sheets if required):
Country
Dates
(mm/yyyy)
Do you have, or have you had, any of the following?
If Yes, approximate date:
(mm/yyyy)
Have you ever been diagnosed with, or had investigations for, one of the following diseases?
Hepatitis B: Yes
/ No
Hepatitis C: Yes
/ No
HIV/AIDS: Yes
/ No
(please note Health Care Workers have a legal and ethical duty to inform Occupational Health if they
suspect or know they are carriers of HIV, Hepatitis B or Hepatitis C)
Have you had a Hepatitis B vaccination?
If you have answered “Yes” please provide an approximate date:
Yes
/ No
(mm/yyyyy)
Please consult http://www.kcl.ac.uk/aboutkings/orgstructure/ps/safety/docs/pgohreq.pdf to see if your
programme will involve Exposure Prone Procedures (EPP) (Orange column). (For information about EPP
please refer to Appendix 2).
My programme involves Exposure Prone Procedures
Pre-Commencement Health Questionnaire
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Yes
/ No
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CONFIDENTIAL to
King’s College Hospital Occupational Health & Wellbeing Department
4. Declaration
Before signing this declaration please ensure that you have completed all the relevant questions as instructed,
proving further details as required.
1. I understand my responsibility to notify Occupational Health if I suspect that I am carrying a serious
communicable condition (such as Hepatitis B / Hepatitis C / HIV or tuberculosis) if my studies bring me into
clinical contact with patients
2. I acknowledge that my personal details will be stored both electronically and on paper by the Occupational
Health & Wellbeing Service in accordance with the Data Protection Act 1998. (This information will be
retained during your period of employment/study and for an additional 40 years to comply with the Control
of Substances Hazardous to Health Regulations where applicable.)
3. If I have any concerns about how this information is handled I am able to contact the Occupational Health
& Wellbeing Department (contact details can be obtained from the university’s Health & Safety Services)
4. I declare that the information provided by me in this form is true and complete to the best of my
knowledge. I understand that any deliberate omission, falsification or misrepresentation in this record will
result in an investigation and may lead to disciplinary action by the King’s College London.
Name/Signature:
Date:
Instructions for Submission
Once completed please email this form and any supporting documentation to kch-tr.KCLOHKings@nhs.net
with the subject heading “Pre-Commencement Health Assessment” and your Full Name.
You will be notified as soon as possible whether any further information or an appointment is required in order
to complete your health assessment.
Queries
If you wish to discuss any of the questions in this form or clarify what is needed please telephone King’s
College Hospital Occupational Health & Wellbeing department on 0203 299 7527 between 0900 and 1230hrs
or email kch-tr.KCLOHKings@nhs.net.
Pre-Commencement Health Questionnaire
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CONFIDENTIAL to
King’s College Hospital Occupational Health & Wellbeing Department
Appendix 1: Guidance on completing this form
Why do you need to complete this form?
Your programme leader/PhD Supervisor has identified that you will be carrying out tasks that may be
affected by your health background (e.g. clinical activities) or may involve potential exposure to hazardous
activities or substances (e.g. microbiological agents, allergens or environmental research). In these cases it
is important to gain a picture of your current state of health, offer you vaccinations etc. (where
appropriate) and to provide advice to yourself and your programme leader where necessary.
Section 3
This form is divided into sections that are relevant to whether your programme will involve work in our
research and teaching laboratories and/or clinical activities.
Please use the pdf programme spreadsheet
(http://www.kcl.ac.uk/aboutkings/orgstructure/ps/safety/docs/pgohreq.pdf) to find your programme and
identify which sections of the form you need to complete.
Section 3a
Please complete this section if you think you have a health condition that may affect, or be affected by, your
studies. Occupational Health will review the information you provide to determine whether you may need
help with adjustments or if there are certain aspects of your proposed studies that could pose a risk to you
because of a particular condition.
Examples of health conditions that may affect, or be affected by, your studies may be:









Musculoskeletal problems (e.g. with your back, neck or joints) that could affect you in work.
Mental health problems (e.g. stress or depression)
Skin problems (e.g. eczema, dermatitis)
Diabetes or epilepsy
Inflammatory bowel disease
Blood borne viruses
Heart or breathing problems
Taking medication or a health condition that reduces your immunity to infectious disease
Any other health condition that may impact on your studies
Please note that if Occupational Health believe that you would benefit from support from the university’s
Disability Advisory Service they will not contact the service without first seeking your written permission.
If you have dyslexia the university’s Disability Advisory Service will be able to provide you with advice and
support: http://www.kcl.ac.uk/campuslife/services/disability/index.aspx
Section 3b
This section is for those studies undertaken in the university’s teaching and research laboratories. Activities
that require health assessment are those involving:




Intentional work with human blood and human tissue,
Intentional biological agents and genetically modified organisms,
Risk of exposure to human pathogens in the environment (e.g. collecting river water samples)
Risk of exposure to allergens
If vaccinations are recommended (e.g. for work with human blood and tissue), health surveillance (for
exposure to allergens) is identified as necessary or your responses in this section indicate that you may be at
increased risk then Occupational Health will contact you to arrange an appointment.
Pre-Commencement Health Questionnaire
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King’s College Hospital Occupational Health & Wellbeing Department
Section 3c
This section is for those studies that will take students into healthcare locations and/or bring students into
contact with patients. It is important for Occupational Health to check that you are not carrying any significant
infectious diseases that will pose a risk to patients and to check that you have up to date vaccinations against
infectious diseases that may be present in the patient population and/or offer advice if your responses
indicate that you may be at increased risk.
For further information about health assessment for clinical activities (and, in particular, exposure prone
procedures) please see Appendix 2.
Section 4
Declaration
Once you have completed the relevant sections of the form (to the best of your knowledge) please email this
to our Occupational Health provider (King’s College Hospital) using the address kch-tr.KCLOHKings@nhs.net
(subject heading “Pre-Commencement Health Assessment” and your Full Name).
Those who will be carrying out any studies in a clinical setting may wish to attach evidence of their immunity
status and any relevant blood test results to assist in the clearance process (see Appendix 2 for further details).
Depending upon the information you have provided and the studies you will be undertaking Occupational
Health may contact you arrange a telephone or face-to-face appointment. Where vaccinations, blood tests or
respiratory health surveillance is needed a face-to-face appointment will be made.
Queries
If you have any queries with regards to the information requested in this form please either contact your
programme lead/PhD supervisor or telephone King’s College Hospital Occupational Health & Wellbeing
Department (telephone 0203 299 7527 (0900 – 1230hrs) or e-mail kch-tr.KCLOHKings@nhs.net) as appropriate.
For more information about health and safety arrangements at King’s College London please see:
http://www.kcl.ac.uk/aboutkings/orgstructure/ps/safety/new/newstudents/oh.aspx
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Appendix 2 - specific guidance for clinical contact with patients
For all students involved in the care of patients or research in clinical areas
If you have/or become diagnosed with an infectious disease, and you will have contact with patients, you must
declare this in confidence to Occupational Health. If aspects of your work may involve a risk of transmission to
patients, you must not carry out such work until the risk has been assessed and any necessary measures to
prevent transmission agreed and implemented.
Exposure prone procedures
Exposure prone procedures (EPP) 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 or 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. Such procedures occur mainly in surgery,
obstetrics and gynaecology, dentistry and some aspects of midwifery. Most nursing duties do not involve EPPs;
exceptions include accident and emergency and theatre nursing.
If your studies involve you undertaking exposure prone procedures you cannot be passed fit for your studies
until the OH Advisers have obtained satisfactory documented evidence of your Hepatitis B infectivity status.
Please note if this is your first studies involving exposure prone procedures or your first studies in the NHS
which will require exposure prone procedures you will need to provide evidence of non-infectivity to Hepatitis
C and HIV. This must be in the form of an identified validated sample (see below). You must inform
Occupational Health if you have ever been tested positive for any transmissible blood-borne virus infection
such as Hepatitis B, Hepatitis C or HIV.
Laboratory test results required for clearance for performing exposure prone procedures must be derived
from an identified validated sample (IVS). An IVS is defined according to the following Department of Health
criteria:
 The healthcare worker should show proof of identity with a photograph – NHS trust identity
driver’s licence with photograph, passport or national identity card – when the sample is taken.
badge,
 The sample of blood should be taken in the Occupational Health Department.
 Samples should be delivered to the laboratory in the usual manner, not transported by the healthcare
worker.
 When results are received from the laboratory, the clinical notes should be checked for a record that the
sample was sent by the Occupational Health department at the relevant time.
The Occupational Health department will accept an original, photocopy or fax of the laboratory report
certificate from either an NHS Trust laboratory or an approved independent U.K laboratory if it contains the
name, address and telephone number of the laboratory in print, the person’s name and date of birth, date of
blood test and result and the Occupational Health Department stamp/signature specifying that the blood
sample was an identified validated sample.
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