HM 143: Tuberculosis Questionnaire for The University of Sheffield

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HM 143: Tuberculosis Questionnaire for The University of Sheffield
This form is confidential to Health Management Ltd. Section 1 should be completed by the Manager
responsible for the employee and then passed to the employee for completion. The employee
should then scan and email it to [email protected]
Section 1 – Referrers Details
Surname
Forename(s)
Faculty or Professional
Services
Reason for Submission:
1. What is the
employee working
with?
2. From your risk
assessment, why do
you feel there is a
risk of TB exposure?
Employee to complete the following sections
Section 2 – Employee Details
Surname
Forename(s)
Date of Birth
Faculty or Professional
Services
Department
Current Job Role
Previous Job Role
Contact Number
HM143 190416 Confidential Employee Name:
DOB:
Page 1 of 4
Home Address &
Postcode
Employee email address
Have you completed this
form before?
Select Yes
or No
tick box: Yes: What Date? MM/YY
If No, Please complete each section of this form in full
If Yes, complete sections 3, 4, 5 & 6 and sign and date form,
before sending to Health Management.
Section 3 – Work History
Job Title
Date appointed to post
Previous employment, dates and positions held
Section 4 – Medical Details
Previous Tests
Yes
No
Not Sure
Have you ever been treated for TB?
Previous Heaf Test or Mantoux Test?
BCG scar present?
Have you worked abroad or travelled significantly?
If yes, please give details of countries and relevant dates
HM143 190416 Confidential Employee Name:
DOB:
Page 2 of 4
Section 5 – Current Medical details
Yes
No
Have you ever had any symptoms of a cough lasting more than 3 weeks?
Have you ever had any symptoms of night sweats?
Have you ever had any symptoms of unexplained weight loss and
tiredness?
Do you suffer from any chronic lung or heart disorder?
Have you ever suffered from any bone marrow disorder or any form of
cancer?
Have you had any treatment with steroids in the past 18 months?
Have you ever suffered from chronic kidney disease?
Do you have any other health problems that may affect your resistance to
infection?
Have you ever had an operation?
Do you suffer from rheumatoid arthritis and/or receiving anti tumour
necrosis factor therapy?
If yes, please give details below
Section 6 – Family History
Yes
No
Not Sure
Is there a family history of TB?
If yes, please give details of who and what contact you have with them (daily, weekly,
monthly, never)
HM143 190416 Confidential Employee Name:
DOB:
Page 3 of 4
Yes
No
Not Sure
Is there any family history of immune-deficiency?
If yes, please give details below
Declaration
I declare that all foregoing statements are true to the best of my knowledge. I further declare that I
have not omitted or falsified any material facts or details, which could have a bearing on my state of
health. I am aware to notify my Manager/Supervisor should any symptoms develop.
I consent to the results of the assessment to be processed and the results provided to my employer
to help safeguard my health, safety and welfare
In signing this form, I confirm my explicit consent within the meaning set out in the Data Protection Act
(1998) for Health Management Limited to process my personal information.
Signed _______________________________________________ Date _____________________
Please scan and email it to [email protected]
Please note ‘fit’ certificates will be sent to [email protected] for onward circulation to the relevant
Manager / Employee.
HM143 190416 Confidential Employee Name:
DOB:
Page 4 of 4
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