HM 144: Periodic questionnaire to assess immunity for individuals who may
be susceptible to infection in the course of their work at 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 TeamA4@healthmanltd.com
Section 1 – Referrers Details
Surname
Forename(s)
Faculty or Professional
Services
What potentially
infectious material is the
employee working with?
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
Home Address &
Postcode
Employee email address
HM144 190416 Confidential Employee Name:
DOB:
Page 1 of 2
Section 3 – Pre-existing risk conditions
Yes
Have you ever suffered from any of the following?

Eczema or chronic skin condition?

Asthma?

Disorders or diseases affecting the immune system?

Chronic illness affecting the lungs, bowels, heart, liver, kidney or
nervous system?
Treatment with steroids, immunosuppressive drugs, anti-tumour
necrosis factor agents or long term antibiotics (e.g. penicillins or
oxytetracycline)

No
Are you currently pregnant or breastfeeding?
If yes, please give details below or add any other comments
In cases of recurrent infections, treatment with antibiotics, steroids or other drugs or other illness
that may affect your immune competence you should inform your Line Manager.
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 TeamA4@healthmanltd.com
Please note ‘fit’ certificates will be sent to occupationalhealth@sheffield.ac.uk for onward circulation to the relevant
Manager / Employee.
HM144 190416 Confidential Employee Name:
DOB:
Page 2 of 2