1
University of Hull
Title:
Student Health Care Worker
Procedure
Ref:
Written by:
Sarah Purdy
Approved by Andrew Snowden HR
Director
Issue:
1
Date:
February 2013
CONTROLLED DOCUMENT
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CONTENTS
Page
1.
PURPOSE
3
2.
SCOPE
3
3.
DEFINITIONS
4
4.
PROCEDURE
4-17
5.
OUTCOME AND PERFORMANCE MEASURES
6.
REFERENCES
17-18
7.
APPENDICES
18-103
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Student Health Care Worker Procedure
1. PURPOSE
1.1 The purpose of this procedure is to outline the process to be followed when assessing
health care/health care related students studying at the University of Hull who are required to
undertake a practice placement as part of their course. To ensure standardisation of the
application of the process by practitioners. The procedure describes the process for
undertaking health care worker assessment in line with current available research, best
practice guidance and Department of Health guidance and other relevant guidance.
2. SCOPE
2.1 The procedure applies to all health care worker students who require health assessment
and health clearance prior to practice placement within the courses, and to the practitioners
involved in the assessment. These students will be undertaking pre-registration courses as
opposed to post-registration courses. The scope of this procedure does not extend to
students undertaking post-registration courses and health assessment for these students is
the responsibility of the sponsoring/seconding organisation. The procedure will not cover
Bio-medical science students as from 2012 it is understood that their course will not have a
practice placement element. Health assessment of non-health care students is covered
under a separate procedure.
2.2 The procedure applies to Nurses who are undertaking ‘return to practice’ courses at the
University
2.2 This procedure applies to health care worker students who are referred to the
department during their course for health related issues in relation to their practice
placement.
2.3 This procedure also captures the health assessment and health clearance of a number
of international visiting health care students who are as part of their visit/course are
undertaking a practice placement.
2.4 Student - mission statement: To provide a customer focused high quality service for
students/prospective students at the University who undertake practice placements within
their course, by; advising students and faculty staff on the impact of health and disability
issues on ‘fitness to practice’.
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3. DEFINITIONS
3.1 Practitioners – Staff in the Occupational Health Department at the University of Hull. This
includes Nurses, Occupational Health Technicians and Physicians.
3.2 Students – Students on health care worker related courses studying or accepted onto
courses at the University of Hull. This may include student Nurses, Midwives, Operating
Department Practitioners, and Medical Students.
3.3 Customers – Staff within the Faculties who have responsibility for students on their
programmes, this includes staff such as Heads of Department, Intake Leaders, Admissions
Tutors, and Disability Tutors.
3.4 Exposure Prone Procedures – Some students are required to have Exposure Prone
Procedure clearance (EPP) this is sometimes referred to as enhanced clearance. This would
include Midwifery, Medical and Operating Department Practitioner Students. Nursing
students and some other students require non-EPP clearance. Exposure prone procedures
(EPPs) are those 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 procedures include those where the
worker's gloved hands may be in contact with sharp instruments, needle tips or sharp
tissues (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.
PROCEDURE
4.1 This procedure will have separate sections for each faculty and their respective student
groups:

Faculty of Health and Social Care (FHSC)

Hull York Medical School (HYMS)
Within each faculty section the pre-training/ pre-course assessment process will be
described followed by the process for referral during training.
4.2 Inappropriate behaviour - the OH Team will treat students, customers and their
representatives with dignity and respect, in return it is expected that Students, customers
and their representatives treat OH team members with dignity and respect. There will be
zero tolerance of inappropriate behaviour including intimidation and harassment. If it is felt
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by a team member that the Students, customer or their representatives are behaving
inappropriately the assessment/meeting/discussion will be ended. If it is a face to face
encounter the individual will be asked to leave the department. The issue may be reported to
the relevant Faculty.
4.3 Faculty Health and Social Care Students – pre-training assessment taking place and
health clearance given prior to course registration: This specifically includes Nurses (Adult,
Child Branch, Learning Disability, and Mental Health), Midwives (both short and full course)
and Operating Department Practitioners.
4.3.1 Please refer to appendix 22 for the flow chart for this process. The faculty
provides an information pack to prospective students once they have been accepted
onto the course (albeit it this may be subject to certain provisions). This information
pack contains some OH documentation – relevant health questionnaire appendix 12
for short course midwives and appendix 12 for all other students; Hepatitis B Initial
information sheet appendix 19; Hand care advice sheet appendix 8 and for Nurses
additionally this includes ‘are you fit to Nurse’ appendix 26. The pack covering letter
asks the student to contact the OH department to arrange an appointment for
assessment. Concurrent to this, admissions provides a regularly updated list to
Occupational health of students who have been offered a place on the course and
who therefore will be contacting the department.
4.3.2 The student contacts the department and a suitable appointment is arranged
once it is confirmed by reference to a list that the student has been asked to contact
the department, the practitioner making the appointment advises the individual if they
need to bring any specific items with them such as photographic identification. They
will also enquire as to whether the individual has completed and returned the health
questionnaire, if they have not done so they are advised to do so prior to their
assessment. The fully completed health questionnaire is required for the assessment
to take place.
4.3.3 The face to face Nurse assessment is undertaken. For student midwives and
ODP students this is an assessment for enhanced clearance for exposure prone
procedure (EPP) work for Nurses this is a non-EPP assessment. Although nurses
may request testing for blood borne viruses in line with EPP assessment. Please
refer to appendix 20 student assessment guidance process document for a
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suggested framework for assessment of declared physical and psychological health
issues. In addition consideration should be given to:

Skin problems; if an individual declares a skin problem or at assessment
there is concern about the skin, they declare any allergies that may increase
their risk of developing sensitisation to products used in a health care setting,
they declare an atopic disease or they declare a latex allergy then the skin
questionnaire ‘appendix 7’ should be completed. From the information on the
questionnaire an appropriate course of action can be decided upon. The
questionnaire should be retained in the individuals OH records.

Skin care; during assessment care of skin whilst on practice placement
should be discussed with the student and a check made to ensure they have
read and understood the skin care advice sheet ‘appendix 8 which was
provided by the faculty in their student pack’. This should be for all students
not just those with skin issues. If they have not read the information or have
lost the sheet then the practitioner may wish to provide this information sheet
again. They should be encouraged to retain this information for the duration of
their training.

Use of the TB Symptom questionnaire: the TB symptom questionnaire
appendix 9 should be used for all students who do not have evidence of
immunity to TB in addition all students from ‘high risk’ countries will be asked
to complete the questionnaire. A TB information sheet will be provided to all
the above students. The completed questionnaire should be retained in the
individual OH records. If there are any concerns about an individual in relation
to TB (latent or active) the TB Nurse team should be contacted for advice.
Students without evidence of immunity to TB will be asked to attend once
registered at a TB clinic where mantoux testing maybe undertaken and where
required BCG vaccination offered. It should be noted that for international
students from high risk countries who wish to be health care workers there is
a requirement to undergo TB screening irrespective of past immunisation.
Please refer to the TB Procedure/process document for further details. If
there are any concerns or questions about students in relation to TB the TB
Nurse team can be contacted for advice.

Whether an individual may be under weight or overweight.
o
Students who may be underweight: For students who report an eating
disorder and look emaciated and there are concerns that they are not
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being managed the practitioner should calculate the students Body
Mass Index (BMI). If their BMI is 15 or below the Higher Education
Occupational Health Practitioners (HEOPS) guidance should be
referred to.
o
Students who may be overweight/ obese: For students who appear to
be over-weight/ obese there is currently no guidance for health care
workers. In the absence of any formal guidance the OH Department
has developed criteria. If at assessment the student has difficulty
sitting in a department chair that has arms and/or difficulty getting
through a department door without turning sideways then a risk
assessment in practice should be recommended to the Faculty in a
report. If the individual has health issues related to their obesity then
the specific health issues should be considered separately within the
assessment process.

Vaccination history/evidence of immunity relevant to practice as a health care
worker; some vaccinations or evidence of immunity are required for practice
as a health care worker.
o
Evidence of 2 Measles, Mumps and Rubella vaccinations (or the
individual equivalent) or evidence of immunity to measles and rubella.
o
Definite history of chicken pox or evidence of immunity to chicken pox
or evidence of 2 varicella vaccinations. For those students who do not
have a definite history of chicken pox or students who do have a
history but originate from a tropical or sub tropical country then a
blood test is required to assess immunity to varicella. In addition to
this the OH department undertake varicella bloods on Midwifery
students and Child Branch student Nurses. The latter is above the
requirements but it is felt that the population with whom they are
working are particularly vulnerable.

Where required dependent upon the evidence/lack of evidence obtained
above vaccination for MMR and Varicella can be provided by the OH
department. Appointments will be arranged directly with students by OH once
registered on the course.

Evidence of BCG vaccination or visualisation of a BCG scar. If this cannot be
provided then the student should be placed on the list of students requiring
assessment by the TB Nurse team at one of their regular clinics. If there is
any uncertainty about immunity to TB then the case should be discussed with
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the TB Nurse team and their advice sought. TB screening and where required
vaccination will only be offered once the student has registered on the course.
The TB clinics are pre-arranged with the Faculty and students are sent
appointment letters by OH.

Hepatitis B vaccination and Seasonal Flu Vaccination. Once the student has
registered on the course they will be offered Hepatitis B vaccination
course/bloods, clinics are arranged with the Faculty to allow student
attendance. Seasonal Flu vaccination is not offered through the University,
but should be available for student on clinical placement at the appropriate
time through the relevant Trusts OH Department.

If despite all options being exhausted a student does not have evidence of
immunity to any of the above then the OH team member will write to the
Faculty using appendix 4 outlining the situation and recommending risk
assessment in clinical placement is undertaken. The risks to the student
should be verbally outlined to them and relevant information provided such as
Varicella leaflet/TB leaflet. They should be encouraged to report any concerns
or relevant symptoms.

Exposure prone procedure (EPP) work; students undertaking the Midwifery
courses (both long and short course) and Operating Department Practitioners
must undergo as part of their assessment enhanced health care worker
clearance, in addition to the above assessment they must be assessed for the
following three blood borne viruses (BBV’s) – Hepatitis B, Hepatitis C and
HIV. Please refer to the vene-puncture procedure for more information. The
blood sample taken for EPP must be an ‘Identified Validated Sample’ IVS.
This means that before the blood sample is taken photographic identification
must be provided. Suggested identification includes photographic driving
licence and passport. Also prior to the blood sample being obtained the
student is provided with the following information sheets to read ‘HIV infected
health care workers – guidance on the management of health care workers’
this is a summary document appendix 14, they are then asked to sign the
following document AIDS/HIV Infected Health Care Workers – Confirmation of
Understanding appendix 15 and Hepatitis C information sheet appendix 16.
The blood sample for assessment of suitability to undertake EPP work will
only be taken with the individual’s written consent. Consent form for a blood
sample to be taken is within the venepuncture procedure. Failure to provide
consent will result in the blood test not being undertaken and the individual
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will not be able to be assessed for suitability to undertake EPP work. The
Faculty would be informed that clearance for EPP work could not be given.

Hepatitis B vaccination or immunity; Hepatitis B vaccination is recommended
for all health care worker. Please refer to the OH department Hepatitis B
procedure and immunisation process. Health clearance is not dependent
upon this vaccination. The Hepatitis B vaccination programme will commence
once students have registered onto their course. The first vaccination
appointment is arranged directly with the Faculty. Appointments thereafter are
arranged between OH and the student.

Once full immunisation history is complete and all relevant vaccinations
received then an immunisation record sheet appendix 21 is completed and emailed to the student. They are advised to keep this for future reference as
they may be required to produce this whilst on clinical placement. A copy is
also put into the individuals OH records.

Should students repeatedly fail to attend vaccination appointments or decline
vaccination for TB/BCG, Varicella and MMR the faculty will be informed of
their immune status and any recommendations for practice placement made.
As part of the above process all information collected and forms completed, including
any reports sent to the Faculty should be documented/ retained in the individual
Occupational Health record. They should be made aware that they are able to
access/view their records upon request. Records should be created and maintained
in line with the OH Clinical Record Keeping procedure. The assessment will be
recorded on the OH database.
4.3.4 If following assessment a decision can be made as to whether health clearance
can be given and this decision is yes health clearance can be given – for all midwives
and Nursing/ODP students with health/disability issues, where brief advice is to be
offered a report of health appendix 6 is sent, if more detailed information is to be
provided then the report format appendix 4 can be used .These are completed and
sent to admissions, the disability tutor and the student. This is done with the student’s
written consent appendix 2. For Nursing and, ODP students without health/disability
issues an entry is made on the relevant section of the student system and a report of
health is not required. If following assessment a decision cannot be made as to
whether the individual can be cleared or not and more information is required a
number of options can be taken. It may be that additional vaccination information is
required which the student can produce at a later date. In this case the process
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would be temporarily suspended until the information is provided and then the
process as above will continue. It may however be that a medical report is required
or the case needs to be passed to the OH Physician for assessment before a
decision can be made. An interim report appendix 5 should be sent to admissions
and, Disability Tutor at this stage.
4.3.5 If a medical report(s) is required with the written consent provided in the health
questionnaire a medical report is requested. The cost of this report is covered by the
University. This consent remains valid for up to 6 months. If the consent to obtain a
medical report section has been completed this should be requested of the individual
at assessment. If a medical report(s) is to be requested the practitioner should inform
the individual. The OH template document for requesting a medical report should be
used and this is contained within the case management procedure for staff. At the
time of requesting the medical report(s) a GP tracker sheet appendix 10 should be
completed for each report requested and placed in the administration folder. The
report request should be faxed and a call made to the practitioner from whom the
report is being requested to ensure the report request has been received. If upon
receipt of the medical report a decision on health clearance can be made and this
decision is that yes the individual can be health cleared then, the process as in 4.3.4
should be followed.
4.3.6 If the individual following receipt of a medical report cannot be health cleared
then the case may be passed to the OHP either for discussion of the case or for
assessment with the OHP. The next available OHP appointment should be offered to
the individual. Whether health clearance can be given or not at this stage the OHP
will provide a report to admissions, disability tutor and the student. It is possible that
the OHP may need to review the student before an opinion can be formed. It is also
possible that a referral to a specialist for assessment with report is required before a
decision can be made. OH would facilitate this and provide a further interim report
appendix 5 to admissions etc. to update them.
4.3.7 If following the process in section 4.3.4 it may be that the case passes directly
to the OHP without a medical report being requested. The process as outlined above
in 4.3.6 should be followed. It is also possible that if a medical report has not been
requested prior to the OHP assessment the OHP may wish to do so the process in
4.3.5 should be followed.
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4.3.8 Once a decision on whether an individual has health clearance or not has been
made and the relevant parties informed the case will be closed and the Occupational
Health records filed. For those health cleared this will be in the respective section of
the student cabinet; and for those not health cleared they should be filed and
retained for a period of 2 years.
4.3.9 Throughout the assessment process copies of all relevant information should
be retained within the OH record this may include, E-mails, continuation sheets,
health questionnaires, and consent forms. Record keeping should be in line with the
OH department’s clinical record keeping procedure.
4.3.10 Note: should the individual be assessed or health clearance given after
course registration then the procedure as set out above should be followed with the
exception that no entry is made on the student system in relation to health clearance
and all students will require a report of health be completed and sent. In this instance
the reports should be sent to the intake leader, disability tutor and student and not
sent to admissions.
4.3.11 Charges for the above student work will be made directly to the FHSC in
conjunction with finance. Charges for pre-registration student work undertaken are
pre-agreed annually between finance and FHSC. These charges are fully inclusive
and include where required Hepatitis B vaccination, Varicella vaccination, MMR
vaccination and TB screening and vaccination. These activities are covered under
separate procedures. They also include medical reports and referral to the OH
Physician – this is not an exhaustive list. Charges are made by finance at two points
during the academic year.
4.3.12 Feedback, both customer (HOD and intake leader) and client (student)
feedback is sought for each annual intake at the end of the first year of the course.
Customer feedback is requested using the questionnaire appendix 30 and client
feedback is requested using the questionnaire in appendix 29. Feedback can be
provided anonymously. The feedback is collated and presented in the OH annual
report.
4.4 FHSC students referred during training:
4.4.1 The Faculty may choose to refer any pre-registration health care student during
the duration of their course where there are concerns about their health in relation to
their practice placement. This may include situations where the trust has completed a
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‘Student health case tracking form’ appendix 37 which raises concerns about a
health issue in relation to practice placement. Referrals from the Faculty to the
Occupational Health department should be made on the referral to Occupational
Health form appendix 18. Please see flow chart appendix 23 for an overview of this
process. Any referral made to the OH department should be with the approval of the
relevant Head of Department. Upon receipt of the referral the case will be ‘triaged’ by
the OH Team. A decision will be made as to whether OH assessment is required or
whether remote advice can be offered on the case without the need for assessment.
Student referral during training is for the purposes of offering health advice in relation
the health aspects of fitness to practice on practice placement. The principles of staff
case management are applied to student assessment in this situation. Please refer to
the case management procedure for more information.
4.4.2 If assessment by an OH Nurse/Advisor is indicated the practitioner managing
the case will write to the individual offering an appointment. The referring HOD will
also be advised of the appointment date and time, they will also be offered the
opportunity to discuss the case with the OH Practitioner. The individual will be
required to complete a written consent (appendix 3) indicating whether they consent
to the assessment or not. If they do not consent to assessment the Faculty will be
advised. If they do consent to assessment following assessment a report will be
written for the referring HOD. The individual has the option to see the report before it
is released. A copy of the report will be retained in the individual’s OH records.
4.4.3 It may be possible to close the case after the above assessment, however it
may be that the individual requires a review appointment, a medical report maybe
required , the case may need to be discussed with the OH Physician or the individual
offered an appointment with the OHP. At the stage where all the questions raised
have been responded to or there is not further advice the practitioner can offer to the
Faculty the case will be closed. If advice is required at a later stage then a further
referral will be required.
4.4.4 Charges are made to the faculty for each individual assessed if the case is
remotely managed no charge is made. The charge for each referral will be made
once the case has been closed. This may include charges for the Nurse assessment,
any medical reports, referrals for assessment and OHP assessment.
4.4.5 Customer feedback (see appendix 28) is requested for student referral cases
when the case is closed. This feedback can be provided anonymously.
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4.5 FHSC International visiting students
4.5.1International student visitors to the University of Hull will require ‘Health Care
Worker’ health assessment prior to undertaking clinical placement within their course.
Please see appendix 25 flow chart – international students. The student should be
sent and asked to complete and, then return the Health Care Student –health
questionnaire appendix 11 prior to arrival in Hull. If they have evidence of
vaccinations or blood test copies of these should be sent with the health
questionnaire. If the health questionnaire is received prior to arrival/appointment it will
be screened by a team member. Should further information be required the OH
Department will make contact with the student. An appointment for the student for
face to face assessment can be made by the Faculty; this can be done prior to the
Students arrival in Hull to ensure they are assessed promptly upon arrival. The
principles for health assessment applied to pre-registration students in 4.3.3 will be
applied to International students. The exception to this is that all bloods tests will be
repeated – please refer to information in appendix 27
4.5.2 A report of health appendix 6 will be completed and sent to the Faculty and a
copy retained in the students OH records.
4.5.3 If vaccinations are indicated approval should be sought from the Faculty that
the funding is available for the vaccinations. If funding is not available vaccinations
cannot be given. In this scenario risks to the student should be explained to them in
detail. For TB/BCG, MMR, Varicella the Faculty should be advised of the individuals
immune status and any recommendations for practice placement made.
4.5.2 Charges – a pre-set per student charge will be made for each health
assessment and an additional charge for any requested vaccinations. The Faculty
will be invoiced directly after the assessment and any vaccinations have been
completed.
4.6 FHSC Return to practice students
4.6.1 Return to practice students will be required to undergo pre-course ‘health care
worker’ health assessment. Once the Faculty has offered a course place to an
individual they notify the OH Department and the individual, the individual will then be
asked to complete and send to OH a health questionnaire. They will also be asked to
contact OH and arrange an appointment. The principles for health assessment
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applied to pre-registration students as in 4.3.3 will be applied to return to practice
students.
4.6.2 Section 4.3.4 to 4.3.9 above should be followed.
4.6.3 Charges for the health assessment will be included in the pre-registration
student assessment charges.
4.7 Hull York Medical School (HYMS) Students pre-course assessment.
4.7.1 Please refer to appendix 24 for the flow chart for this process. Student health
questionnaire see appendix13 are issued by HYMS to all students offered a place on
the course. In addition to the health questionnaire students are sent by HYMS a
‘Hepatitis B and Hepatitis C information sheet’ appendix 19 and 16 and, a ‘Hand care
advice sheet’ for health care students appendix 8. All the health questionnaires come
into the University of Hull OH Department. Each health questionnaire is screened
and if there are concerns about an individual and it is felt that more information is
required then this process will begin immediately. There is no extra charge for this
work. During the summer the OH Department will be advised by HYMS which
students will go to York and which to Hull. The questionnaires and any associated
paperwork pertaining to York students are collected together and sent to the OH
department at York NHS Trust. The paperwork pertaining to Hull students is retained
in the department here in Hull.
4.7.2 Each student will undergo EPP health assessment. Students are assessed face
to face as soon as possible after registration the same process for health
assessment is followed as in 4.3.3. If following assessment once the EPP Blood
results have been received a decision can be made as to whether health clearance
can be given and, this decision is yes health clearance can be given then a report of
health is sent to HYMS and a copy to the student see appendix 34. If more detailed
advice is to be offered then the report format appendix 4 can be used, however if the
appendix 4 format is used to provide a health opinion then the students written
consent should be obtained see appendix 35.
4.7.3 If following assessment a decision cannot be made as to whether the individual
can be cleared or not and more information is required a number of options can be
taken. It may be that additional vaccination information is required which the student
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can produce at a later date. In this case the process would be temporarily suspended
until the information is provided and then the process as above will continue. It may
however be that a medical report is required or the case needs to be passed to the
OH Physician for assessment before a decision can be made. An interim report
appendix 33 should be sent to the School at this stage.
4.7.4 If a medical report(s) is required with the written consent provided in the health
questionnaire a medical report should be requested. The cost of this report is
covered by the University. This consent remains valid for up to 6 months. If the
consent to obtain a medical report section has not been completed this should be
requested of the individual at assessment. If a medical report(s) is to be requested
the practitioner should inform the individual. The OH template document for
requesting a medical report should be used and this is contained within the case
management procedure for staff. At the time of requesting the medical report(s) a
report tracker sheet appendix 10 should be completed for each report requested and
placed in the administration folder. The report request should be faxed and a call
made to the practitioner from whom the report is being requested to ensure the report
request has been received. If upon receipt of the medical report a decision on health
clearance can be made and this decision is that yes the individual can be health
cleared then, the process as in 4.7.2 should be followed.
4.7.5 If the individual following receipt of a medical report cannot be health cleared
then the case may be passed to the OHP either for discussion of the case or for
assessment with the OHP. The next available OHP appointment should be offered to
the individual. Whether health clearance can be given or not at this stage the OHP
will provide a report to the school and the student. It is possible that the OHP may
need to review the student before an opinion can be formed. It is also possible that a
referral to a specialist for assessment with report is required before a decision can be
made. OH would facilitate this and provide a further interim report appendix 33 to
HYMS to update them.
4.7.6 If following the process in section 4.7.1 it may be that the case passes directly
to the OHP without a medical report being requested. It is also possible that if a
medical report has not been requested prior to the OHP assessment the OHP may
wish to do so the process in 4.7.2 should be followed.
4.7.7 Once a decision on whether an individual has health clearance or not has been
made and the relevant parties informed the case will be closed and the Occupational
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Health records filed. For those health cleared this will be in the respective section of
the student cabinet; and for those not health cleared they should be filed and
retained for a period of 2 years.
4.7.8 Throughout the assessment process copies of all relevant information should
be retained within the OH record this may include, E-mails, continuation sheets,
health questionnaires, and consent forms. Record keeping should be in line with the
OH department’s clinical record keeping procedure.
4.7.9 Charges for each EPP student assessment undertaken will be made directly to
the SHA for the intake once all the students have been assessed and vaccinated.
4.8 HYMS referral during training assessment
4.8.1 The School may choose to refer any medical student during the duration of
their course where there are concerns about their health in relation to their practice
placement. For referral of a HYMS student to University of Hull OH department a
referral form see appendix 31 should be completed. If the students pre-training
assessment took place in York then the OH Department in Hull will not have any OH
records. A request to York NHS Trust OH Department should be made as per the
consent in the health questionnaire to request a copy of the OH records. Upon
receipt of the referral the case will be ‘triaged’ by the OH Team. A decision will be
made as to whether OH assessment is required or whether remote advice can be
offered on the case without the need for assessment. Student referral during training
is for the purposes of offering health advice in relation the health aspects of fitness to
practice on practice placement. The principles of staff case management are applied
to student assessment in this situation. Please refer to the case management
procedure for more information.
4.8.2 If assessment by an OH Nurse/Advisor or OH Physician is indicated the
practitioner managing the case will write to the individual offering an appointment.
The person referring will also be advised of the appointment date and time, they will
also be offered the opportunity to discuss the case with the OH Practitioner. The
individual will be required to complete a written consent (appendix 3) indicating
whether they consent to the assessment or not. If they do not consent to assessment
the person referring will be advised. If they do consent to assessment, following the
assessment a report will be written for the referring individual. The individual has the
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option to see the report before it is released. A copy of the report will be retained in
the individual’s OH records.
4.8.3 It may be possible to close the case after the above assessment, however it
may be that the individual requires a review appointment, and/or a medical report
maybe required , the case may need to be discussed with the OH Physician or the
individual offered an appointment with the OHP if the initial appointment was with an
OHA. At the stage where all the questions raised have been responded to or there is
no further advice the practitioner can offer to the School the case will be closed. If
advice is required at a later stage then a further referral will be required.
4.8.4 Charges will be made directly to the SHA for any work undertaken once the
case is closed and, the charges will very dependent upon whether the student has
been assessed by an OH Nurse, an OH Physician or whether specialist assessments
have been undertaken/medical reports have been obtained – or any combination of
these. If the case is remotely managed no charge will be made.
5. OUTCOMES AND PERFORMANCE MEASURES
5.1 Pre-registration student health care worker assessment is undertaken in line with current
available research, best practice and without adverse clinical incident in respect to personnel
and practitioners.
5.2 The total number of students undergoing health assessment and the proportion declined
health clearance.
5.3 Customer and client feedback requested at the end of year one of study and the number
of complaints received
5.4 The number of adverse clinical incidents
6. REFERENCES AND INFORMATION
Hepatitis B procedure and immunisation process V1 - X:/OH folder/Quality/Policies/Hepatitis
B
Varicella procedure and immunisation process - X:/OH folder/Quality/Policies/Varicella
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MMR procedure and immunisation process –X:/OH folder/Quality/Policies/MMR
Vene-puncture procedure V1 – X:/OH folder/Quality/Policies/Vene-puncture
TB screening and vaccination procedure X:/OH folder/Quality/Policies/TB
Case management procedure X:/OH folder/Quality/Policies/Case Management
Clinical record keeping procedure X:/OH folder/Quality/Policies/Clinical Record Keeping
Department of Health (2007) Health clearance for tuberculosis, hepatitis B, hepatitis C and
HIV: New healthcare workers.
http://www.dh.gov.uk/en/Publichealth/Communicablediseases/HepatitisB/HepatitisBgenerali
nformation/index.htm
Department of Health (2006) The Green Book Immunisation against infectious disease.
London. Updates on
http://www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/DH_409725
4
Nursing and Midwifery Council (NMC):2008 Good Health Good Character: Guide for
educational institutions
http://www.nmc-uk.org
Health Professions Council (HPC): Guidance on health and character http://www.hpc-uk.org
General Medical Council (GMC): Medical Students Professional Values and Fitness to
Practice
http://www.gmc-uk.org
HEOPS Guidance to study with severe eating disorders
http://www.heops.org.uk
7. APPENDICES
Appendix 1 Front Sheet Health Care Professional – Staff and Students
Appendix 2 Pre-registration assessment – Consent Form, FHSC
Appendix 3 Referral during training – Consent Form
Appendix 4 Confidential Occupational Health report
Appendix 5 FHSC Interim statement report of health
Appendix 6 FHSC Report of Health for Health Care Students
Appendix 7 Initial Skin Questionnaire
Appendix 8 Hand Care Advice for Health Care Students
Appendix 9 Tuberculosis Symptoms Screening Questionnaire
Appendix 10 GP Tracker Sheet
Appendix 11 Nursing/Midwifery/ODP Students Health Questionnaire
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Appendix 12 Short Course Midwifery Students Health Questionnaire
Appendix 13 Hull York Medical School (HYMS) Students Health Questionnaire
Appendix 14 HIV Infected Health Care Workers Guidance Summary
Appendix 15 AIDS/HIV Infected Health Care Workers – Confirmation of Understanding
Appendix 16 Hepatitis C information sheet
Appendix 17 Blood Borne Virus Risk Assessment
Appendix 18 Health Professional Students – Referral to Occupational Health Form
Appendix 19 Hepatitis B Immunisation – information sheet
Appendix 20 Student Assessment Guidance – Process Document
Appendix 21 Immunisation record
Appendix 22 Flow chart – FHSC Pre-registration assessment of health care student’s
process
Appendix 23 Flow chart – FHSC ‘During training’ referral of health care student’s
process
Appendix 24 Flow chart – HYMS Students Pre-registration assessment of Medical
Students process
Appendix 25 Flow chart – Assessment of International students process
Appendix 26 Are you fit to Nurse?
Appendix 27 Health Care Students – pre-registration health assessment information
Appendix 28 Customer feedback questionnaire–referral during training
Appendix 29 FHSC student feedback questionnaire–end of year one
Appendix 30 FHSC customer feedback questionnaire for cohort at end of year one
Appendix 31 HYMS Students – Referral to Occupational Health Form
Appendix 32 Student Vaccination Flow Chart HYMS and FHSC
Appendix 33 – HYMS Interim statement report of health
Appendix 34 – HYMS Report of health for Medical students
Appendix 35 – Pre-registration assessment – consent form, HYMS
Appendix 36 - Flow chart – HYMS referral during training
Appendix 37 – Student Health Case – ‘Tracking Form’
Appendix 38 – Consent for obtaining immunisation related information
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Occupational Health
Department
Appendix 1
Health Care Professionals – Staff and Students
Course & Cohort
or Department
Name (in full)
Title
Mr/Mrs/Ms/Miss/Dr/Other
Date of Birth
Address
E-Mail Address
Telephone Number
Mobile Number
Immunisation history
Date Immunised
MMR 1
MMR 2
Heaf/Mantoux
BCG
Varicella – history of infection
Varicella 1
Varicella 2
Hepatitis B 1
Hepatitis B 2
Hepatitis B 3
Hepatitis B booster
Other
Blood tests
Date tested
Hepatitis B Antibody
Hepatitis B Surface Antigen
Hepatitis C
HIV
Varicella
Rubella
Measles
Mumps
Other
*IVS – Identified Validated Sample
*EPP - Exposure Prone Procedure
Health Clearance
Given
Date given
Yes/No
Practitioner Name
Outcome
Date
Outcome
*IVS - Yes/No
*EPP Cleared
Yes/No
Date given
Signature
Title
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Name
............................................................. Job Title ......................................................
Date of Birth .................................................... Department ..................................................
Date &
Time
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Occupational Health
Department
Appendix 2
CONSENT FORM – PRE-TRAINING ASSESSMENT, FHSC
Personal Details
Surname:
First Name(s):
Date of Birth:
Address:
Post Code:
Consent for a report to be sent to the FHSC by the Faculty’s health advisor
Following your pre training health assessment by an OH Team Member, it is necessary for a
report outlining your medical condition to be sent to the admissions department within the
Faculty of Health and Social care. The focus of the report would be to provide information to
assist the Faculty in supporting you whilst on practice placement and will be briefly outlined
to you prior to the end of your assessment. The Faculty may need to share this information
with the practice placement provider. If you withhold consent this may impact on practice
placement, it is possible that you may be excluded from clinical practice. A copy will be sent
to you.
I do / do not consent for this information to be disclosed
Signed: ……………………………………………… Date:
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Occupational Health
Department
Appendix 3
CONSENT FORM – REFERRAL DURING TRAINING
Please complete parts A and B of this form. Only complete part C if asked to do so by the OH Team
Member.
Part A – Personal Details
Surname:
First Name(s):
Date of Birth:
Address:
Post Code:
Part B – Consent to Assessment and Report by the Faculty/Schools health advisor
Following the assessment by an OH Team Member a report will be sent to your referring
team. You have the option to view this report prior to its release. The report will be briefly
outlined to you prior to the end of your appointment.
I do / do not consent to this assessment and report.
I do / do not wish to receive a copy of the report
I do / do not wish to see the report before it is supplied. You will have 2 working days to
read the report, if there is anything in it which you consider incorrect or misleading you can
request (this must be in writing) that the OH practitioner amend the report. He/she is not
obliged to do so. Comments received in writing within the timescales will be attached to the
report. If you withhold consent this may impact on practice placement, it is possible that you
may be excluded from clinical practice.
Signed: ………………………………………………Date: …………..……………………………
Part C – Consent to obtain a medical report from a family doctor or specialist
I consent to medical information being supplied to the Occupational Health Department at
The University of Hull. The information will be used to assist us in the management of your
case. I have been given a summary of my rights under the Access to Medical Reports Act
1988.
I do / do not wish to see the report before it is supplied.
Doctor(s) from whom a report will be requested
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GP (name)
Address
Specialist (name)
Address
Post Code
Post Code
Signed: ……………………………….……………..Date: ……..………………………………………
Part C cont – to be retained by the individual
Summary of your principal rights under the access to Medical Reports Act 1988
This is a summary of your principal rights under the above act which is concerned with report
provided by a medical practitioner who is or has been responsible for your clinical care.
Option A: You may withhold your consent to an application for the report from a medical
practitioner but should note that the inability to obtain up-to-date medical information may affect
decisions made about your suitability for work placements by the University.
Option B: You may consent to the application for a report, but indicate your wish to see the report
before it is supplied. You must make your own arrangements to see the report it will not be
automatically sent to you.
The medical practitioner will be informed that you wish to see the report and will allow 21 days for
you to view and approve it before it is sent to the Occupational Health Department. If the Medical
Practitioner has not heard from you in writing within 21 days of the application for the report being
made he/she will assume that you do not wish to see the report and that you consent to it being
supplied. When you see the report if there is anything in it which you consider incorrect or
misleading you can request (this must be in writing) that the medical practitioner amend the
report. He/she is not obliged to do so. If the medical practitioner refuses to amend it you may:
1) Withdraw consent for the report to be issued
2) Ask the medical practitioner to attach to the report a statement setting out your own views
3) Agree to the report being issued unchanged
Note: The Medical Practitioner is not obliged to show you any parts of the report which they
believe might cause serious harm to your physical or mental health or that of others, or which
would reveal information about a third party or the identity of a third party who has supplied the
practitioner with information about your health unless the third party also consents. In those
circumstances the Medical Practitioner will also inform you. Your access to the report will be
appropriately limited.
Option C: You may consent to the application for the report but indicate that you do not wish to
see the report before it is supplied. Should you change your mind after the application is made
and notify the medical practitioner in writing they should allow 21 days to elapse after such
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notification so that you may arrange to have access to the report (if the report has not already
been supplied before you changed your mind).
Option D: Whether or not you decide to seek access to the report before it is supplied, you have
the right to seek access to it from the medical practitioner at any time up to 6 months after it was
supplied.
Information acquired will be included in the student health record in accordance with the Data
Protection Act 1998.
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Occupational Health
Department
Appendix 4
Date
Tuesday, 09 February 2016
From
To
Cc
Your Content here
OH Action
Kind Regards
[Signature]
[Title]
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Occupational Health
Department
Appendix 5
Interim Statement – Report of Health, FHSC
Student Pre-course Health Assessment
This interim report is provided to the University to advise of the current position regarding the
health assessment process for the student named below
To: Admissions, FHSC and student named below
Student Full Name:
DOB
Course/Cohort:
The above named student has undergone – please delete *:
Health questionnaire assessment
*Yes/No
Health screening
* Yes/No
Medical assessment
* Yes/No
The current situation – please delete those not applicable:
OH are awaiting requested medical information
Further assessment is required – an appointment has been sent to the individual
by the team
Specialist assessment is recommended and the OH department will facilitate this
PLEASE NOTE: The pre-course health assessment process has not yet been completed.
You will receive a ‘report of health’ when the process is complete
Remarks/ Recommendations:
Name
Signature
Title
Date
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Occupational Health
Department
Appendix 6
Report of Health – Student Pre-course Health Assessment, FHSC
This report of health provides an opinion to the University about any health/disability issues
in relation to ‘fitness to practice’ on practice placement. The University may wish to share
this information with a practice placement provider.
To: Admissions, FHSC, Student named below
Student full name:
DOB:
Course/Cohort:
The above named student has undergone – please delete *:
Health questionnaire assessment
* Yes/No
Health screening
* Yes/No
Medical assessment
* Yes/No
Opinions offered – please delete whichever statements are not relevant:
The above student has been provided with health clearance for the above course
The above student has not been provided with health clearance for the above
course
Health clearance given to undertake exposure prone procedure work
Yes/No/Not Applicable
Equality Act 2010
- is likely to apply at this stage
- is not likely to apply at this stage
-applicability is unclear at this stage
Remarks/Recommendations – including recommendations on obstacles to practice, reasonable adjustment
for practice placement and any further OH action:
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Occupational Health
Department
Name:
Signature:
Title:
Date:
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Appendix 7
Health care Student
Initial Skin Screening Questionnaire
Name
Date of Birth
Course
Cohort
History
Do you have Eczema, Dermatitis, Psoriasis?
Details
Yes/No
Do you have any other skin condition?
Are you using prescribed medication on your
skin?
Yes/No
Do you regularly use hand creams?
Do you have problems using any hand wash
soaps, alcohol rubs or other?
Yes/No
Yes/No
Yes/No
Signs & Symptoms on fingers or hands
Redness and swelling
Yes/No
Cracking of skin
Yes/No
Blisters
Yes/No
Flaking or scaly skin
Yes/No
Itchy skin
Yes/No
Allergies
Do you have any food allergies?
Yes/No
Do you suffer from hay fever/asthma?
Do you have any allergies to natural rubber latex
i.e. balloons, rubber gloves, condoms, rubber
bands?
Have you ever had rash, redness, itching or
swelling anywhere on the body when in contact
with latex?
Yes/No
Yes/No
Yes/No
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OCCUPATIONAL HEALTH USE ONLY
Physical Examination:
Comments/Advice
Name:
Designation:
Signature:
Date:
Refer to OHP:
Yes/No
Report sent to Faculty:
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32
Occupational Health
Department
Appendix 8
Hand Care Advice for Health Care Students
Introduction
Intact skin creates an excellent barrier against organisms entering the body. When
skin is not in good condition then this barrier breaks down causing the potential for
infection which you could spread to the patients in your care. Some hand hygiene
products such as wash lotions or alcoholic hand sanitizers can increase dryness to
skin in people with thinner more sensitive skin. This is worsened dramatically in the
colder winter months.
What to Expect.
Dryness appears as flaky, cracked and in extreme cases hands can become red,
inflamed and sore which could become a source for infection. The most common
areas of dryness appear across the knuckles and between fingers where skin is
thinnest. However everyone’s skin is different so this is not limited.
Best Practice.
If you are experiencing dryness the first step is to review your hand hygiene practice.
Dryness can be considerably reduced and controlled by ensuring the following
practice is followed.

Use luke warm water to wash hands – NOT HOT!
Hot water melts away the natural fats found in the surface layer of the skin.
When these fats are removed the surface layer of the skin dries out and
becomes cracked and brittle. If you do not have mixer taps use cold water.

Wet hands before applying the wash lotion to the skin.
Wetting hands first puts a layer of water between your hands and the wash
lotion, this helps with foaming but also means it is easier to rinse off. Residues
left on skin can cause irritation especially if your skin is already dry and
cracked as the detergent is able to get below the surface protective layer of
the skin and into the living cells.

Following the step technique (will be taught in clinical skills).
Follow the step technique for washing and also rinsing to ensure all areas of
the hands are free from dirt, micro organisms and wash lotion residues.
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
Do not disinfect hands with an alcoholic hand sanitizer directly after
washing.
To perform a hand hygiene episode you should either wash or sanitize. It is
not necessary to use the alcoholic hand sanitizer after washing and if your
hand are still wet and your pores open from washing with warm water the
alcohol can get into the living layers of the skin and will cause a stinging
sensation.

Dry hands thoroughly.
Especially in winter if hands are not dried properly the weather outside and
heating systems inside can cause extreme dryness, or exaggerate smaller
issues.

Moisturise regularly
Use a pea size amount of unscented hand cream at the start and end of your
shift and any other time you feel you need it. Hand washing, wearing gloves,
hand disinfectant can all remove moisture from the skin, to keep the protective
surface layer of the skin in good condition we must replace moisture when
required. The backs of the hands loose the most moisture and also absorb the
most moisture so rub the cream into the back of the hands first.

Look after your hands outside of work too.
We all know certain jobs around the house that cause dryness to hands such
as gardening, washing the pots and general cleaning. If you are doing any of
these jobs, wear gloves and protect your hands. In the winter, wear gloves at
all times when outside, to protect them from the cold weather.
The above advice should be followed at all times not just when skin
becomes dry.
If you have an underlying skin condition such as eczema or psoriasis and are
presently experiencing problems with the condition that is affecting your
forearms/hands you may need specialist advice/treatments. Please contact your GP
for advice. You will also be assessed at your pre-training health assessment.
If you experience problems with your skin whilst on clinical placement, in the first
instance please speak to your Practice Learning Facilitator who will advise, you may
also wish to inform you course leader.
University Occupational Health Unit contact details: - T: 01482 466010
occupationalhealth@hull.ac.uk
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Occupational Health
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Appendix 9
Tuberculosis Symptoms Screening Questionnaire
Name: ______________________
Dept/Cohort: ________________
Date of Birth: _________________
Staff/Student: ________________
Please answer the following questions.
Do you have any of the following symptoms?
Yes
No
1. A persistent cough that has lasted over three weeks and has got
progressively worse.
2. Loss of weight for no obvious reason.
3. Fever and heavy night sweats.
4. A general and unusual sense of tiredness and being unwell.
5. Coughing up blood.
The above health statement is accurate to the best of my knowledge. I will inform
Occupational health if my health status changes.
_________________________________
Signature
___/___/___
Date
For use by Occupational Health. Action taken if yes answer to above questions
______________________________________________________________________
______________________________________________________________________
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Appendix 10
Occupational
Health
Department
Student
Name
GP TRACKER SHEET
Student Date of Birth
Email:
Referring Officers Contact Details
Name
Telephone no:
GP / Specialist Name
GP/ Specialist Address
GP / Specialist Telephone No
Does the employee wish to see the
report before it is sent to OH?
ADVISORY TIME
PERIOD
YES / NO
ACTION
Date report request sent:
COMMENTS
(Continue over page as needed)
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1
Day of faxing
report request
Phone call to confirm receipt of report request, if invoice
payment is waiting before the report is released.
2
28 days
First chase
3
35 days
Second chase
49 days
Fourth chase - E-mail referring officer with above information
and agree future action e.g.: send final report without benefit
of GP / consultant information on which HR will have to base
their decision, continue chasing report at regular intervals.
4
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Occupational Health
Department
Appendix 11
Nursing/Midwifery/Operating Department Practitioner Students
Health Questionnaire
The questionnaire below when completed will be reviewed by a member of the Occupational Health team. A
health opinion on suitability for clinical practice as a health care student will be given to the Admissions tutor or
Programme Leader.
Please return this completed questionnaire to the Occupational Health Department:
University of Hull
Cottingham Road
Hull
HU6 7RX
Complete all relevant sections and provide details where appropriate. There is additional space at the end of the
form where there is insufficient space in the box provided. At the end you will be asked to sign a declaration,
indicating that you have answered the questions truthfully and to the best of your knowledge.
Section 1. To be completed by the Faculty
Course Title.......................................................................................................................
Section 2a. To be completed by the student
Surname.......................................................First Name(s).....................................................
Title Mrs/Miss/Ms/Mr/Other......................................DOB........................................................
Previous surname................................................................................... Male/Female
Address...................................................................................................................................
................................................................................................................................................
...........................................................................................Post Code....................................
Contact Telephone Number(s)...............................................................................................
E-mail address..............................................................Country of Birth................................
Section 2b.
* please delete whichever is not relevant
Have you previously undertaken a health care course at the University of Hull? * YES/NO
Have you had health screening or medical examination for employment in health care
before?
*YES/NO
If yes please provide details...................................................................................................
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Student name and DOB....................................................................................................
Section 3. To be completed by the Student
Do you need any equipment/adaptations to assist you at your clinical placement?
YES/NO
Do you feel you have any disabilities and/or learning difficulties?
YES/NO
If yes please provide more detail.............................................................................................
................................................................................................................................................
Do you have or have you ever had
Mental Health issues, depression, anxiety,
psychosis? self harmed or have a eating
disorder?
Psychiatric, or psychological treatment or
counselling?
Disorders affecting, back, neck, shoulders,
hand, arm knees, hips, arthritis?
Gastric tract disorders, bowel or stomach
problems? Hernia or rupture?
Heart or circulatory problems? Raised blood
pressure, angina, chest pain palpitations?
A urinary tract disorder, kidney or bladder
problem?
Breathing problems, asthma COPD, bronchitis,
persistent cough? Chest disease?
Visual problems? ear, nose or throat problems?
Skin problems, eczema, psoriasis, dermatitis?
Chronic Fatigue?
Disorders of the nervous system? Epilepsy,
fainting, balance problems, dizziness Migrane
or frequent headaches?
Diabetes or other endocrine disorders?
Are you pregnant or breastfeeding?
Known allergies, including latex?
Any impairment affecting communication?
Drug or alcohol misuse?
Are you attending hospital or your G.P or
receiving any medical treatment at present?
Do you take any medication, have injections or
use any ointments regularly?
Have you had any operations, serious
accidents
or
illnesses
not
previously
mentioned?
Yes
No
Details (If answered yes)
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Student name and DOB.....................................................................................................
Section 4. To be completed by the student section 4a and their G.P practice section 4b
4a)
Have you had any of the
following infectious
diseases?
Measles
Mumps
Rubella (German Measles)
Chicken Pox
Whooping cough
Diphtheria
Hepatitis
Typhoid or paratyphoid
Have you ever had tuberculosis
(TB), do you have a family
history of TB or close contact
with anyone suffering from TB?
Yes
No
Don’t
Know
Details
Please indicate in which country your immunisations were given .............................................
4b) Immunisation history -to be completed by the GP practice or previous
occupational health provider ONLY (a printout of the information will be accepted)
Yes
No
Date
Comment
TB skin test (Heaf, Mantoux)
BCG
Hep B 1
Hep B 2
Hep B 3
Hep B surface antibody
MMR1
MMR 2
Rubella
Rubella titre level
Varicella Immunity
Other –please specify
Note- If the G.P practice cannot provide the above information this form should still be signed and stamped
by the G.P Practice
Comments:
Signature of practitioner.................................................................................................
Title ............................................................................... Date........................................
Practice stamp:
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Student name and DOB..............................................................................................
Section 5. To be completed by the student
5a) Declaration
In signing this questionnaire you are confirming that all the information is true to the best
of your knowledge. You accept that if it is subsequently shown that relevant medical
information has not been disclosed or has been misleading or false, in some
circumstances you may reasonably be regarded as unfit for work placements.
The University of Hull complies with data protection legislation. In signing this declaration
you confirm that you have given your consent to the University of Hull to process your
personal information with respect to your work placement. This form will form part of your
student health record, which will be retained by the University for the period of your
course of study.
It may be required that you attend for health screening or medical assessment in relation
to the work placement health assessment. In signing this declaration you confirm your
consent to undergo further medical assessment in relation to the work placement health
assessment process.
Dependent upon the responses above the University of Hull may require further medical
information via a report. Further medical information can only be sought with written
informed consent from yourself. Please see box below
Student signature..................................................................... Date...................................
5b) Consent
Please read and retain information in section 6 below before completing this section
I understand my rights under the Access to Medical Reports Act 1988 and have read the
summary of principal rights. This consent will remain valid for a period of up to six
months from signing. A copy of this consent shall have the validity of the original.
*Please delete whichever is not applicable
*I consent to a medical report being obtained OR I do not consent to a medical report
being obtained
*I wish to see the report before it is sent OR I do not wish to see the report before it is
sent
Name and contact details of G.P from whom a report may be requested
Name and contact details of specialist or health care professional from which a report
may be requested
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41
Student signature.........................................................................Date...............................
Additional information (please attach further sheets as required, with your name
and date of birth on)
APPENDIX 1 -To be retained by the student
Summary of your principal rights under the access to Medical Reports Act 1988
This is a summary of your principal rights under the above act which is concerned with report
provided by a medical practitioner who is or has been responsible for your clinical care.
Option A: You may withhold your consent to an application for the report from a medical
practitioner but should note that the inability to obtain up-to-date medical information may affect
decisions made about your suitability for work placements by the University.
Option B: You may consent to the application for a report, but indicate your wish to see the report
before it is supplied. You must make your own arrangements to see the report it will not be
automatically sent to you.
The medical practitioner will be informed that you wish to see the report and will allow 21 days for
you to view and approve it before it is sent to the Occupational Health Department. If the Medical
Practitioner has not heard from you in writing within 21 days of the application for the report being
made he/she will assume that you do not wish to see the report and that you consent to it being
supplied. When you see the report if there is anything in it which you consider incorrect or
misleading you can request (this must be in writing) that the medical practitioner amend the
report. He/she is not obliged to do so. If the medical practitioner refuses to amend it you may:
1) Withdraw consent for the report to be issued
2) Ask the medical practitioner to attach to the report a statement setting out your own views
3) Agree to the report being issued unchanged
Note: The Medical Practitioner is not obliged to show you any parts of the report which they
believe might cause serious harm to your physical or mental health or that of others, or which
would reveal information about a third party or the identity of a third party who has supplied the
practitioner with information about your health unless the third party also consents. In those
circumstances the Medical Practitioner will also inform you. Your access to the report will be
appropriately limited.
Option C: You may consent to the application for the report but indicate that you do not wish to
see the report before it is supplied. Should you change your mind after the application is made
and notify the medical practitioner in writing they should allow 21 days to elapse after such
notification so that you may arrange to have access to the report (if the report has not already
been supplied before you changed your mind).
Option D: Whether or not you decide to seek access to the report before it is supplied, you have
the right to seek access to it from the medical practitioner at any time up to 6 months after it was
supplied.
Information acquired will be included in the student health record in accordance with the Data
Protection Act 1998.
University of Hull student health care worker procedure August 2012 V1
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APPENDIX 2 – Student to retain
Operating Department Practitioners, Nurses and Midwives
The attached questionnaire is intended to support the health assessment process. In a small
minority of cases health clearance may be given based upon the information in the health
questionnaire; however the majority of health care students will need to attend an
Occupational Health appointment to complete the assessment process.
Health care workers including student Nurses, Operating Department Practitioners (ODP)
students, Midwifery students and Medical students need a high standard of physical and
mental fitness to enter and remain in the health care worker profession. Different groups of
health care workers are governed by their relevant professional body, the healthcare worker
medical fitness standards are however similar. In addition to the governing professional
bodies the Department of Health sets out clear health criteria for health care workers.
In relation to the health assessment process to gather all the information we require to offer
a health opinion we may take a number of options these include: obtaining with consent a
medical report, assessment by an Occupational Health Nurse, assessment by an
Occupational Health Physician, referral to a specialist for assessment with report.
Health care workers can be divided into two subgroups those undertaking exposure prone
procedures (EPP) and those not undertaking EPP. Those undertaking EPP require
‘enhanced’ health clearance and include Midwives, ODP’s and Medical students
Your health assessment will be completed as quickly as possible but we cannot guarantee
completing the health assessment process prior to your preferred registration date, this will
depend upon a number of factors including when you contact us to arrange an appointment,
whether the questionnaire is complete, whether you require referral to a Physician or
whether we need to obtain a medical report. Registration onto a course however is a
decision for the faculty and not Occupational Health.
Relevant documents:
Department of Health 2007. Health clearance for tuberculosis, hepatitis B, hepatitis C and
HIV
Nursing and Midwifery Council 2008 Good Health Good Character: Guide for educational
institutions
Health Professions Council: guidance on health and character
College of Operating Department Practitioners: student standards
University of Hull student health care worker procedure August 2012 V1
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Occupational Health
Department
Appendix 12
Short Course Midwifery Students
Health Questionnaire
The questionnaire below when completed will be reviewed by a member of the Occupational Health team. A
health opinion on suitability for clinical practice as a health care student will be given to the Admissions tutor or
Programme Leader.
Please return this completed questionnaire to the Occupational Health Department:
University of Hull
Cottingham Road
Hull
HU6 7RX
Complete all relevant sections and provide details where appropriate. There is additional space at the end of the
form where there is insufficient space in the box provided. At the end you will be asked to sign a declaration,
indicating that you have answered the questions truthfully and to the best of your knowledge.
Section 1. To be completed by the Faculty
Course Title.......................................................................................................................
Section 2a. To be completed by the student
Surname.......................................................First Name(s).....................................................
Title Mrs/Miss/Ms/Mr/Other......................................DOB........................................................
Previous surname................................................................................... Male/Female
Address...................................................................................................................................
................................................................................................................................................
...........................................................................................Post Code....................................
Contact Telephone Number(s)...............................................................................................
E-mail address.......................................................................................................................
Section 2b.
* please delete whichever is not relevant
Have you previously undertaken a health care course at the University of Hull? * YES/NO
Have you had health screening or medical examination for employment in health care
before?
*YES/NO
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If yes please provide details...................................................................................................
Student name and DOB....................................................................................................
Section 3. To be completed by the Student
Do you need any equipment/adaptations to assist you at your clinical placement?
YES/NO
Do you feel you have any disabilities and/or learning difficulties?
YES/NO
If yes please provide more detail.............................................................................................
................................................................................................................................................
Do you have or have you ever had
Mental Health issues, depression, anxiety,
psychosis? self harmed or have a eating
disorder?
Psychiatric, or psychological treatment or
counselling?
Disorders affecting, back, neck, shoulders,
hand, arm knees, hips, arthritis?
Gastric tract disorders, bowel or stomach
problems? Hernia or rupture?
Heart or circulatory problems? Raised blood
pressure, angina, chest pain palpitations?
A urinary tract disorder, kidney or bladder
problem?
Breathing problems, asthma COPD, bronchitis,
persistent cough? Chest disease?
Visual problems? ear, nose or throat problems?
Skin problems, eczema, psoriasis, dermatitis?
Chronic Fatigue?
Disorders of the nervous system? epilepsy,
fainting, balance problems, dizziness Migrane
or frequent headaches?
Diabetes or other endocrine disorders?
Are you pregnant or breastfeeding?
Known allergies, including latex?
Any impairment affecting communication?
Drug or alcohol misuse?
Are you attending hospital or your G.P or
receiving any medical treatment at present?
Do you take any medication, have injections or
use any ointments regularly?
Have you had any operations, serious
accidents
or
illnesses
not
previously
mentioned?
Yes
No
Details (If answered yes)
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Student name and DOB.....................................................................................................
Section 4. 4aTo be completed by the student and section 4b by their current
Occupational Health Department
4a)
Have you had any of the
following infectious
diseases?
Measles
Mumps
Rubella (German Measles)
Chicken Pox
Whooping cough
Diphtheria
Hepatitis
Typhoid or paratyphoid
Have you ever had tuberculosis
(TB), do you have a family
history of TB or close contact
with anyone suffering from TB?
Yes
No
Don’t
Know
Details
4b) Immunisation history – This section to be completed by the current OH Dept not the University of
Hull OH Dept
Yes
No
Date
Comment
TB skin test (Heaf, Mantoux)
BCG
Hep B 1
Hep B 2
Hep B 3
Hep B surface antibody
MMR1
MMR 2
Rubella
Rubella titre level
Varicella Immunity
Other –please specify
Note- If the OH dept cannot provide the above information this form should still be signed and stamped by
the OH dept
Comments:
Signature of practitioner.................................................................................................
Title ............................................................................... Date........................................
OH department stamp:
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Student name and DOB..............................................................................................
Section 5. To be completed by the student
5a) Declaration
In signing this questionnaire you are confirming that all the information is true to the best
of your knowledge. You accept that if it is subsequently shown that relevant medical
information has not been disclosed or has been misleading or false, in some
circumstances you may reasonably be regarded as unfit for work placements.
The University of Hull complies with data protection legislation. In signing this declaration
you confirm that you have given your consent to the University of Hull to process your
personal information with respect to your work placement. This form will form part of your
student health record, which will be retained by the University for the period of your
course of study.
It may be required that you attend for health screening or medical assessment in relation
to the work placement health assessment. In signing this declaration you confirm your
consent to undergo further medical assessment in relation to the work placement health
assessment process.
Dependent upon the responses above the University of Hull may require further medical
information via a report. Further medical information can only be sought with written
informed consent from yourself. Please see box below
Student signature..................................................................... Date...................................
5b) Consent
Please read and retain information in section 6 below before completing this section
I understand my rights under the Access to Medical Reports Act 1988 and have read the
summary of principal rights. This consent will remain valid for a period of up to six
months from signing. A copy of this consent shall have the validity of the original.
*Please delete whichever is not applicable
*I consent to a medical report being obtained OR I do not consent to a medical report
being obtained
*I wish to see the report before it is sent OR I do not wish to see the report before it is
sent
Name and contact details of G.P from whom a report may be requested
Name and contact details of specialist or health care professional from whom a report
may be requested
Student signature.........................................................................Date...............................
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Additional information (please attach further sheets as required, with your name
and date of birth on)
APPENDIX 1 -To be retained by the student
Summary of your principal rights under the access to Medical Reports Act 1988
This is a summary of your principal rights under the above act which is concerned with report
provided by a medical practitioner who is or has been responsible for your clinical care.
Option A: You may withhold your consent to an application for the report from a medical
practitioner but should note that the inability to obtain up-to-date medical information may affect
decisions made about your suitability for work placements by the University.
Option B: You may consent to the application for a report, but indicate your wish to see the report
before it is supplied. You must make your own arrangements to see the report it will not be
automatically sent to you.
The medical practitioner will be informed that you wish to see the report and will allow 21 days for
you to view and approve it before it is sent to the Occupational Health Department. If the Medical
Practitioner has not heard from you in writing within 21 days of the application for the report being
made he/she will assume that you do not wish to see the report and that you consent to it being
supplied. When you see the report if there is anything in it which you consider incorrect or
misleading you can request (this must be in writing) that the medical practitioner amend the
report. He/she is not obliged to do so. If the medical practitioner refuses to amend it you may:
1) Withdraw consent for the report to be issued
2) Ask the medical practitioner to attach to the report a statement setting out your own views
3) Agree to the report being issued unchanged
Note: The Medical Practitioner is not obliged to show you any parts of the report which they
believe might cause serious harm to your physical or mental health or that of others, or which
would reveal information about a third party or the identity of a third party who has supplied the
practitioner with information about your health unless the third party also consents. In those
circumstances the Medical Practitioner will also inform you. Your access to the report will be
appropriately limited.
Option C: You may consent to the application for the report but indicate that you do not wish to
see the report before it is supplied. Should you change your mind after the application is made
and notify the medical practitioner in writing they should allow 21 days to elapse after such
notification so that you may arrange to have access to the report (if the report has not already
been supplied before you changed your mind).
Option D: Whether or not you decide to seek access to the report before it is supplied, you have
the right to seek access to it from the medical practitioner at any time up to 6 months after it was
supplied.
Information acquired will be included in the student health record in accordance with the Data
Protection Act 1998.
University of Hull student health care worker procedure August 2012 V1
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48
APPENDIX 2 – Student to retain
Operating Department Practitioners, Nurses and Midwives
The attached questionnaire is intended to support the health assessment process. In a small
minority of cases health clearance may be given based upon the information in the health
questionnaire; however the majority of health care students will need to attend an
Occupational Health appointment to complete the assessment process.
Health care workers including student Nurses, Operating Department Practitioners (ODP)
students, Midwifery students and Medical students need a high standard of physical and
mental fitness to enter and remain in the health care worker profession. Different groups of
health care workers are governed by their relevant professional body, the healthcare worker
medical fitness standards are however similar. In addition to the governing professional
bodies the Department of Health sets out clear health criteria for health care workers.
In relation to the health assessment process to gather all the information we require to offer
a health opinion we may take a number of options these include: obtaining with consent a
medical report, assessment by an Occupational Health Nurse, assessment by an
Occupational Health Physician, referral to a specialist for assessment with report.
Health care workers can be divided into two subgroups those undertaking exposure prone
procedures (EPP) and those not undertaking EPP. Those undertaking EPP require
‘enhanced’ health clearance and include Midwives, ODP’s and Medical students
Your health assessment will be completed as quickly as possible but we cannot guarantee
completing the health assessment process prior to your preferred registration date, this will
depend upon a number of factors including when you contact us to arrange an appointment,
whether the questionnaire is complete, whether you require referral to a Physician or
whether we need to obtain a medical report. Registration onto a course however is a
decision for the faculty and not Occupational Health.
Relevant documents:
Department of Health 2007. Health clearance for tuberculosis, hepatitis B, hepatitis C and
HIV
Nursing and Midwifery Council 2008 Good Health Good Character: Guide for educational
institutions
Health Professions Council: guidance on health and character
College of Operating Department Practitioners: student standards
University of Hull student health care worker procedure August 2012 V1
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Appendix 13
Hull York Medical School (HYMS) Students
Health Questionnaire
The questionnaire below when completed will be reviewed by an Occupational Health Advisor. A health opinion
on suitability for clinical practice as a medical student will be given to Admissions. This information will be treated
as medically confidential. The information provided will be assessed by the relevant Occupational Health
Departments utilised by HYMS.
Please return this completed questionnaire to the Occupational Health Department:
University of Hull
Cottingham Road
Hull
HU6 7RX
Complete all relevant sections and provide details where appropriate. There is additional space at the end of the
form where there is insufficient space in the box provided. At the end you will be asked to sign a declaration,
indicating that you have answered the questions truthfully and to the best of your knowledge.
Please note: when you attend for health screening in the OH Dept you will need to bring a form of photographic
identification (for example a passport) with you.
PLEASE ENSURE THIS FORM IS COMPLETED AND RETURNED WITHIN 14DAYS TO THE
OCCUPATIONAL HEALTH DEPARTMENT
Section 1a. To be completed by the student
Surname.......................................................First Name(s).....................................................
Title Mrs/Miss/Ms/Mr/Other......................................DOB........................................................
Previous surname................................................................................... Male/Female
Address...................................................................................................................................
................................................................................................................................................
...........................................................................................Post Code....................................
Contact Telephone Number(s)...............................................................................................
E-mail address...........................................................Country of birth....................................
Section 1b.
* please delete whichever is not relevant
Have you previously undertaken a health care course at the University of Hull? * YES/NO
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Have you had health screening or medical examination for employment in health care
before?
*YES/NO
If yes please provide details...................................................................................................
Student name and DOB....................................................................................................
Section 2. To be completed by the Student
Do you need any equipment/adaptations to assist you at your clinical placement?
YES/NO
Do you feel you have any disabilities and/or learning difficulties?
YES/NO
If yes please provide more detail.............................................................................................
................................................................................................................................................
Do you have or have you ever had
Mental Health issues, depression, anxiety,
psychosis? self harmed or have a eating
disorder?
Psychiatric, or psychological treatment or
counselling?
Disorders affecting, back, neck, shoulders,
hand, arm knees, hips, arthritis?
Gastric tract disorders, bowel or stomach
problems? Hernia or rupture?
Heart or circulatory problems? Raised blood
pressure, angina, chest pain palpitations?
A urinary tract disorder, kidney or bladder
problem?
Breathing problems, asthma COPD, bronchitis,
persistent cough? Chest disease?
Visual problems? ear, nose or throat problems?
Skin problems, eczema, psoriasis, dermatitis?
Chronic Fatigue?
Disorders of the nervous system? epilepsy,
fainting, balance problems, dizziness Migraine
or frequent headaches?
Diabetes or other endocrine disorders?
Are you pregnant or breastfeeding?
Known allergies, including latex?
Any impairment affecting communication?
Drug or alcohol misuse?
Are you attending hospital or your G.P or
receiving any medical treatment at present?
Do you take any medication, have injections or
use any ointments regularly?
Have you had any operations, serious
accidents
or
illnesses
not
previously
mentioned?
Yes
No
Details (If answered yes)
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Student name and DOB.....................................................................................................
Section 3. Section 3a to be completed by the student and section 3b to be completed by
their G.P practice
3a)
Have you had any of the
following infectious
diseases?
Measles
Mumps
Rubella (German Measles)
Chicken Pox
Whooping cough
Diphtheria
Hepatitis
Typhoid or paratyphoid
Have you ever had tuberculosis
(TB), do you have a family
history of TB or close contact
with anyone suffering from TB?
Yes
No
Don’t
Know
Details
Please indicate in which country your immunisations were given .............................................
3b) Immunisation history - to be completed by the GP practice or previous
occupational health provider ONLY (a printout of the information will be accepted)
Yes
No
Date
Comment
TB skin test (Heaf, Mantoux)
BCG
Hep B 1
Hep B 2
Hep B 3
Hep B surface antibody
MMR1
MMR 2
Rubella
Rubella titre level
Varicella Immunity
Other –please specify
Note- If the G.P practice cannot provide the above information this form should still be signed and stamped
by the G.P Practice
Comments:
Signature of practitioner.................................................................................................
Title ............................................................................... Date........................................
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Practice stamp:
Student name and DOB..............................................................................................
Section 4. To be completed by the student
4a) Declaration/consent
In signing this questionnaire you are confirming that all the information is true to the best
of your knowledge. You accept that if it is subsequently shown that relevant medical
information has not been disclosed or has been misleading or false, in some
circumstances you may reasonably be regarded as unfit for work placements.
The University of Hull complies with data protection legislation. In signing this declaration
you confirm that you have given your consent to the University of Hull to process your
personal information with respect to your work placement. This form will form part of your
student health record, which will be retained by the University for the period of your
course of study.
You will be required to attend for health screening or medical assessment in relation to
assessment of fitness for clinical placement. In signing this declaration you confirm your
consent to undergo further medical assessment in relation to overall assessment of
fitness for clinical practice.
You consent for transfer of copies of your OH records between other Hull York Medical
School Occupational health providers, in accordance with Access to Health records Act
(1990) and the Data Protection Act (1998).
Dependent upon the responses above the University of Hull may require further medical
information via a report. Further medical information can only be sought with written
informed consent from yourself. Please see box below
Student signature..................................................................... Date...................................
4b) Consent
Please read and retain information in section 5 below before completing this section
I understand my rights under the Access to Medical Reports Act 1990 and have read the
summary of principal rights. This consent will remain valid for a period of up to six
months from signing. A copy of this consent shall have the validity of the original.
*Please delete whichever is not applicable
*I consent to a medical report being obtained OR I do not consent to a medical report
being obtained
*I wish to see the report before it is sent OR I do not wish to see the report before it is
sent
Name and contact details of G.P from whom a report may be requested
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Name and contact details of specialist or health care professional from whom a report
may be requested
Student signature.........................................................................Date...............................
Additional information (please attach further sheets as required, with your name
and date of birth on)
APPENDIX 1 To be retained by the student
Summary of your principal rights under the access to Medical Reports Act 1988
This is a summary of your principal rights under the above act which is concerned with report
provided by a medical practitioner who is or has been responsible for your clinical care.
Option A: You may withhold your consent to an application for the report from a medical
practitioner but should note that the inability to obtain up-to-date medical information may affect
decisions made about your suitability for work placements by the University.
Option B: You may consent to the application for a report, but indicate your wish to see the report
before it is supplied. You must make your own arrangements to see the report it will not be
automatically sent to you.
The medical practitioner will be informed that you wish to see the report and will allow 21 days for
you to view and approve it before it is sent to the Occupational Health Department. If the Medical
Practitioner has not heard from you in writing within 21 days of the application for the report being
made he/she will assume that you do not wish to see the report and that you consent to it being
supplied. When you see the report if there is anything in it which you consider incorrect or
misleading you can request (this must be in writing) that the medical practitioner amend the
report. He/she is not obliged to do so. If the medical practitioner refuses to amend it you may:
1) Withdraw consent for the report to be issued
2) Ask the medical practitioner to attach to the report a statement setting out your own views
3) Agree to the report being issued unchanged
Note: The Medical Practitioner is not obliged to show you any parts of the report which they
believe might cause serious harm to your physical or mental health or that of others, or which
would reveal information about a third party or the identity of a third party who has supplied the
practitioner with information about your health unless the third party also consents. In those
circumstances the Medical Practitioner will also inform you. Your access to the report will be
appropriately limited.
Option C: You may consent to the application for the report but indicate that you do not wish to
see the report before it is supplied. Should you change your mind after the application is made
and notify the medical practitioner in writing they should allow 21 days to elapse after such
notification so that you may arrange to have access to the report (if the report has not already
been supplied before you changed your mind).
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Option D: Whether or not you decide to seek access to the report before it is supplied, you have
the right to seek access to it from the medical practitioner at any time up to 6 months after it was
supplied.
Information acquired will be included in the student health record in accordance with the Data
Protection Act 1998.
APPENDIX 2 – Student to retain
Medical students
The attached questionnaire is intended to support the health assessment process. Medical
students will need to attend an Occupational Health appointment with an Occupational
Health Nurse to complete the assessment process.
Health care workers including student Nurses, Operating Department Practitioners (ODP)
students, Midwifery students and Medical students need a high standard of physical and
mental fitness to enter and remain in the health care worker profession. Different groups of
health care workers are governed by their relevant professional body, the healthcare worker
medical fitness standards are however similar. In addition to the governing professional
bodies the Department of Health sets out clear health criteria for health care workers.
In relation to the health assessment process, to gather all the information we require to offer
a health opinion, we may take a number of options these include: obtaining with consent a
medical report, assessment by an Occupational Health Physician, referral to a specialist for
assessment with report.
Health care workers can be divided into two subgroups those undertaking exposure prone
procedures (EPP) and those not undertaking EPP. Those undertaking EPP require
‘enhanced’ health clearance and include Midwives, ODP’s and Medical students.
All Medical students are health assessed after registration. Appointments will be assigned to
you by HYMS to take place during October. Health questionnaires are screened prior to your
assessment and where appropriate further information obtained. Your health assessment
will be completed as quickly as possible however the length of time taken to offer a health
opinion to HYMS depends on a number of factors including whether the health questionnaire
is complete, whether you require referral to an OH Physician or whether we need to obtain a
medical report.
You will be copied into the report of health sent to HYMS following completion of your health
assessment.
Relevant documents:
University of Hull student health care worker procedure August 2012 V1
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55
Occupational Health
Department
Department of Health 2007. Health clearance for tuberculosis, hepatitis B, hepatitis C and
HIV
General Medical Council: Medical Students Professional Values and Fitness to Practice
Appendix 14
HIV INFECTED HEALTH CARE WORKERS
GUIDANCE ON THE MANAGEMENT OF HEALTH CARE WORKERS
DEPARTMENT OF HEALTH JUNE 2005
SUMMARY OF KEY POINTS AND RECOMMENDATIONS
Management of infected health care workers
1. These guidelines apply to all health care workers in the NHS and
private sectors, including visiting health care workers and students.
(Paragraph 1.1)
2. All health care workers are under ethical and legal duties to protect the
health and safety of their patients. They also have a right to expect that
their confidentiality will be respected and protected. (Paragraph 1.4)
3. Provided appropriate infection control precautions are adhered to
Scrupulously, the majority of procedures in the health care setting pose no
risk of transmission of the human immunodeficiency virus (HIV) from an
infected health care worker to a patient. (Paragraph 1.5)
4. The circumstances in which HIV could be transmitted from a health care
worker to a patient are limited to exposure prone procedures in which
injury to the health care worker could result in the worker’s blood
contaminating the patient’s open tissues (“bleed-back”). HIV infected
health care workers must not perform any exposure prone procedures.
(Paragraphs 1.6 and 3.4)
5. The Expert Advisory Group on AIDS recommends that, as far as is
practicable, patients should only be notified if they have been at distinct
risk of bleed-back from the particular exposure prone procedures
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performed on them by an HIV infected health care worker. Such patients
should be contacted and encouraged to have pre-test discussion and HIV
antibody testing. (Paragraph 1.7)
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6. The decision on whether a patient notification exercise is undertaken
should be made on a case-by-case basis using risk assessment. It is
anticipated that in most cases this decision will be made locally by
Directors of Public Health (DsPH) of Primary Care Trusts (PCTs),
supported as necessary by Regional Epidemiologists or Regional Directors
of Public Health. Where there is still uncertainty, the United Kingdom
Advisory Panel for Health Care Workers Infected with Blood-borne
Viruses (UKAP) may also be approached for advice. (Paragraph 1.8)
7. HIV infected health care workers must not rely on their own assessment of
the risk they pose to patients. (Paragraph 4.6)
8. A health care worker who has any reason to believe they may have been
exposed to infection with HIV, in whatever circumstances, must promptly
seek and follow confidential professional advice on whether they should be
tested for HIV. Failure to do so may breach the duty of care to patients.
(Paragraph 4.7)
9. Examples of how a person in the UK may have been exposed to HIV
infection include if they have:
• engaged in unprotected sexual intercourse between men;
• shared injecting equipment whilst misusing drugs;
• had unprotected heterosexual intercourse in, or with a person who
had been exposed in, a country where HIV transmission through
sexual intercourse between men and women is common;
• engaged in invasive medical, surgical, dental or midwifery
procedures in parts of the world where infection control
precautions may have been inadequate;
• had a significant occupational exposure to HIV infected material
in any circumstances.
10. Additionally, a person who is aware that they had unprotected sexual
intercourse with someone in any of the above categories may also have
been exposed to HIV infection. (Paragraph 4.8)
11. Health care workers who are infected with HIV must promptly seek
appropriate expert medical and occupational health advice. If no
occupational physician is available locally, consideration should be given
to contacting one elsewhere. Those who perform or may be expected to
perform exposure prone procedures must obtain further expert advice
about modification or limitation of their work practices to avoid exposure
prone procedures. Procedures which are thought to be exposure prone
must not be performed whilst expert advice is sought. (Paragraph 4.9)
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12. If there is uncertainty whether an HIV infected worker has performed
exposure prone procedures, a detailed occupational health assessment
should be arranged. The UKAP can be consulted by the occupational
health physician, the health care worker or a physician on their behalf if
there is doubt. The health care worker’s identity should not be disclosed
to the UKAP. (Paragraph 4.10)
13. If it is believed that any exposure prone procedures have been performed
and that a patient notification exercise needs to be considered, the infected
health care worker or their chosen representative (e.g. the occupational or
HIV physician) should inform the Director of Public Health (DPH) of the
relevant Primary Care Trust on a strictly confidential basis. The DPH or a
delegated colleague (e.g. the Consultant in Communicable Disease
Control (CCDC)) will in turn make an appraisal of the situation to decide
whether a patient notification exercise is necessary, consulting Regional
Epidemiologists or Regional Directors of Public Health, and UKAP, if
necessary. The medical director of the employing trust should also be
informed in confidence at this stage. (Paragraphs 4.11 and 4.12)
14. HIV infected health care workers who do not perform exposure prone
procedures but who continue to provide clinical care to patients mustremain under regular
medical and occupational health supervision. They
should follow appropriate occupational health advice, especially if their
circumstances change. (Paragraph 4.14)
15. Health care workers who know or have good reason to believe (having
taken steps to confirm the facts as far as practicable) that an HIV infected
worker is practising in a way which places patients at risk, or has done so
in the past, must inform an appropriate person in the infected worker’s
employing authority (e.g. a consultant occupational health physician) or,
where appropriate, the relevant regulatory body. The DPH should also be
informed in confidence. The UKAP can be asked to advise when the need
for such notification in unclear. Such cases are likely to arise very rarely.
Wherever possible the health care worker should be informed before
information is passed to an employer or regulatory body. (Paragraph 4.17)
16. All employers in the health care setting should ensure that new and existing
staff (including agency and locum staff and visiting health care workers) are
aware of this guidance and of the professional regulatory bodies’ statements
of ethical responsibilities, and occupational health guidance for HIV/AIDS
infected health care workers. (Paragraph 5.1)
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17. Medical, dental, nursing and midwifery schools, colleges and universities
should draw students’ attention to this guidance and the relevant
professional statements. (Paragraph 5.2)
18. Where an employer or member of staff is aware of the health status of
an infected health care worker, there is a duty to keep such information
confidential. (Paragraph 5.3)
19. Employers should assure infected health care workers that their status
and rights as employees will be safeguarded so far as is practicable.
Where necessary, employers should make every effort to arrange suitable
alternative work and retraining opportunities, or where appropriate early
retirement, for HIV infected health care workers, in accordance with good
general principles of occupational health practice. (Paragraph 5.4)
20. All matters arising from and relating to the employment of HIV infected
health care workers should be co-ordinated through a specialist
occupational health physician. (Paragraph 6.1)
21. Patient safety and public confidence are paramount and dependent on the
HIV infected, or potentially infected, health care worker observing their
duty of self-declaration to an occupational physician. Employers should
promote a climate which encourages such confidential disclosure. It is
extremely important that HIV infected health care workers receive the
same rights of confidentiality as any patient seeking or receiving medical
care. (Paragraph 6.7)
Taken from:
HIV-infected health care workers: Guidance on management and patient notification,
Department of Health, July 2005
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Occupational Health
Department
Appendix 15
AIDS/HIV Infected Health Care Workers
Guidance on the Management of Infected Health Care Workers
Department of Health July 2005
I have read the key recommendations of the above document and understand my responsibilities
under the guidance provided by the Department of Health.
Name (please print):
Signature:
Job Title:
Date:
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Occupational Health
Department
Appendix 16
HEPATITIS C
Hepatitis C is a serious disease of the liver caused by a virus. Hepatitis means inflammation of the liver.
Sometimes it can be brought on by alcohol or drugs but usually it is caused by a virus. There are several
different types of virus known to cause hepatitis. One virus causing increasing concern amongst Health
Professionals is Hepatitis C which is a blood borne virus. The incubation period, from exposure to the
virus until the onset of the disease is one to six months Symptoms of Hepatitis C vary considerably from
flu like symptoms to an acute illness with abdominal pain and jaundice. Many will be unaware that they
have sustained the infection. The consequences of hepatitis infection vary from one individual to
another, these can include, chronic liver disease, cancer of the liver and in severe cases death. Twenty
per cent of people will clear the virus at the acute stage; the remaining eighty percent will remain
infected. This carrier state can persist for many years.
Hepatitis C is transmitted via blood and other body fluids. The most common cause of transmission in
Health Care Workers is via needle stick injury or blood splashes to mucous membrane. Cuts and skin
lesions can also provide a portal of entry. Hepatitis C is spread in the general population through sharing
contaminated equipment for drug injection. Sexual transmission is possible but unusual. Infection may
also have been acquired from receipt of unscreened blood or untreated plasma products (in the UK prior
to September 1991 for blood, and 1985 for plasma).
The spread of Hepatitis C can be prevented amongst Health Care Workers by good practice and
adoption of 'Universal Precautions' a system of good practice regardless of whether the situation is
considered high risk or not.
The Department of Health issued new guidance in August 2002 ‘Hepatitis C Infected Healthcare Workers’
http://www.doh.gov.uk/hepatitisc the aim of the guidance is to prevent the transmission of Hepatitis C
from Health Care Workers to patients. The guidance only applies to Health Care Workers involved in
‘exposure prone procedures.’
EXPOSURE PRONE PROCEDURES (EPPs) are defined as:Invasive procedures where there is a risk that injury to the health care worker may result in the exposure
of the patient’s open tissue to the blood of the worker. They include procedures where the worker’s
gloved hand may be in contact with sharp instruments, needle tips or sharp tissue (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. (DOH Dec.2002)
Health Care Workers who are intending to undertake professional training for a career that relies upon
the performance of exposure prone procedures will be tested for antibodies to the Hepatitis C Virus prior
to their first SHO post and if positive, for Hepatitis C virus RNA. Those found to be Hepatitis C virus RNA
positive should be restricted from starting such training whilst they are carrying the virus.
Testing for Hepatitis C will be compulsory prior to embarking on exposure prone procedures.
Anyone found to be Hepatitis C antibody positive will be recalled to the Occupational Health Unit for
advice and further testing. A positive test would indicate a history of Hepatitis C infection.
A positive result would prevent commencement of areas of training involving EPPs until further tests and
treatment had been implemented. Refusal to undergo testing would be treated as a positive result.
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DOH guidelines are still under review, you will be informed of any changes.
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Occupational Health
Department
Appendix 17
Blood borne Virus Risk Assessment
Please read and ensure you understand your professional responsibilities to protect patients
from infection with serious communicable disease, i.e. Hepatitis C, HIV, Hepatitis B.
Risk Assessment
During the 6 months before your last blood test for blood borne viruses and subsequently
have you been at risk of exposure by:




Being occupationally exposed to the blood or other high risk body fluid of a patient
by percutaneous (sharps) injury, contact with broken skin or mucous membrane
known to be infected or deemed at high risk of a blood borne infection.
Being involved as a health care worker or patient in exposure prone procedures in
parts of the world where infection control precautions may have been inadequate or
in populations with a high prevalence of blood borne viruses.
Having received unscreened blood (in the UK prior to September 1991) or untreated
plasma products (in the UK prior to 1985).
Sharing of injecting equipment whilst misusing drugs.
Engaged in unprotected sexual intercourse particularly with individuals in high risk
groups.
I have/have not been at risk of infection from any blood borne virus. (Please delete as
appropriate).
If you have been at risk was this within the last 6 months
Yes/No
To the best of my knowledge I am not infected with a blood borne virus.
I have accurately assessed my risk of exposure to blood borne viruses as required by my
professional responsibilities and will advise the occupational health department if my risk of
blood borne virus infection changes
Name _________________________ Signature __________________ Date __/__/_
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Occupational Health
Department
Appendix 18
Health professional students – Referral to Occupational Health form, FHSC
For completion by Tutors. Please complete and return this form to the Occupational Health
department for any Students you wish to refer to OH. Upon receipt of this completed form an
appointment will be offered to the student.
Section 1. Tutor details
Tutor Name
Contact details
Section 2. Student details
Student Name
Programme
Cohort
Section 3 The health issue
3a Please briefly outline the health issue – use additional sheet if required
3b Please outline your concerns about the health issue in relation to clinical practice
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Section 4.Actions taken
Please specify what actions have taken place to date to manage this case
Section 5. Information required
Please specify here what information your require from OH and the questions you would like
addressed
Section 6.
Tutor signature
Date
Section 7.
HOD Signature
Date
Please note: the appropriate HOD must countersign this form otherwise OH are unable to accept the
referral
HOD - please tick this box
to confirm approval for funding of referral has been obtained from the
Education Commissioning lead.
Please note: unless confirmation of funding is provided OH are unable to accept the referral
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Appendix 19
Hepatitis B Immunisation
People at increased risk of contracting hepatitis B should be immunised. The hepatitis B
vaccine is also very effective at preventing infection with hepatitis B if you have been at risk
from a possible source of infection (for example a needlestick injury) and you are not
immunised.
What is hepatitis B?
Hepatitis B is a disease caused by the hepatitis B virus. The disease mainly affects the liver.
However, if you are infected the virus is present in body fluids such blood, saliva, semen and vaginal
fluid. In the UK it is estimated that about 1 in 1000 people are infected with the hepatitis B virus. It is
much more common in other countries - these include sub-Saharan Africa, most of Asia and the
Pacific islands.
If you are infected with the hepatitis B virus, the initial symptoms can range from no symptoms at all to
a severe illness. After this 'acute phase', in a number of cases the virus remains in the body longterm. These people are called 'carriers'. Some carriers do not have any symptoms but can still pass
on the virus to other people.
How is hepatitis B passed on?
The hepatitis B virus is passed from person to person as a result of:
 Blood to blood contact. For example: drug users sharing needles or other equipment which
may be contaminated with infected blood.
 Having unprotected sex with an infected person.
 From an infected mother passing it to her baby.
 A human bite from an infected person.
Who needs hepatitis B immunisation?
Anyone who is at increased risk of being infected with the hepatitis B virus should consider being
immunised. These include:
 Workers who are likely to come into contact with blood products, or are at increased risk of
needlestick injuries, assault, etc. For example: nurses, doctors, dentists, medical laboratory
workers, prison wardens, etc. Also, staff at day care or residential centres for people with
learning disabilities where there is a risk of scratching or biting by residents.
 People who inject street drugs, their sexual partners and children.
 People who change sexual partners frequently (in particular homosexual men and sex
workers).
 People who live in close contact with someone infected with hepatitis B. (You cannot catch
hepatitis B from touching people or normal social contact. However, close regular contacts
are best immunised.)
 People who regularly receive blood transfusions (for example people with haemophilia).
 People who live in residential accommodation for those with learning difficulties. People who
attend day centres for people with learning difficulties may also be offered immunisation.
 Families adopting children from countries with a high or intermediate prevalence of hepatitis B
when the hepatitis B status of the child is unknown. (It is, however, advisable for the child to
be tested for hepatitis B.)
The immunisation schedule
You need three doses of the vaccine for full protection. The second dose is usually given one month
after the first dose. The third dose is given five months after the second dose.
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One month after the third dose you may need to have a blood test. You may need one if you are at
risk of infection at work, especially as a healthcare or laboratory worker or have certain kidney
diseases. Your doctor will be able to advise you if you need a blood test. This checks if you have
made antibodies against the hepatitis B virus and are immune. This is because for about 1 in 10
people, three doses of the vaccine are not sufficient and a booster is needed after five years.
Rapid immunisation schedule- A schedule of giving three doses quicker than usual may be used in
some situations.
Are there any side-effects from hepatitis B immunisation?
Side-effects are uncommon. Occasionally, some people develop soreness and redness at the
injection site. Rarely, some people develop a mild fever and a flu-like illness for a few days after the
injection.
What if I come into contact with hepatitis B and am not immunised?
Seek medical attention as soon as possible if you have been at risk from a possible source of
infection and you are not immunised. For example, if you have a needlestick injury or have been
bitten by someone who may have hepatitis B, etc.
You should have an injection of immunoglobulin as soon as possible. This contains antibodies against
the virus and gives short term protection. You should also start a course of immunisation. The
hepatitis B vaccine is very effective at preventing infection if given shortly after contact with hepatitis
B.
Who should not receive hepatitis B vaccine?


If you have an illness causing a high temperature it is best to postpone immunisation until
after the illness.
You should not have a booster if you have had a severe reaction to this vaccine in the past.
Further information
Information on immunisation
Web: www.immunisation.org.uk
From the NHS aimed at the general public.
The Hepatitis B Foundation UK
The Great Barn, Godmersham Park, Canterbury, Kent, CT4 7DT
Tel: 01227 738279 Web: www.hepb.org.uk
One of their aims is to raise awareness about the prevention of hepatitis B virus (HBV) infection,
including the key role of immunisation.
References



Immunisation against infectious disease - 'The Green Book', Department of Health (various
dates)
Boxall EH, A Sira J, El-Shuhkri N, et al; Long-term persistence of immunity to hepatitis B after
vaccination during infancy in a country where endemicity is low. J Infect Dis. 2004 Oct
1;190(7):1264-9. Epub 2004 Aug 27. [abstract]
No authors listed; Are booster immunisations needed for lifelong hepatitis B immunity?
European Consensus Group on Hepatitis B Immunity. Lancet. 2000 Feb 12;355(9203):561-5.
[abstract]
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has
used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care
professional for diagnosis and treatment of medical conditions. For details see our conditions.
© EMIS 2008 Reviewed: 14 Nov 2008 DocID: 4269 Version: 38
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Appendix 20
Student assessment guidance – Process document
Introduction:
This process outlines the assessment of physical and mental health issues as part of the student pretraining health assessment. It is intended for use in face to face assessment, but the framework
principles could be applied in a telephone assessment and the principles also used for student
referrals. It is one element of a wider health assessment. It is intended as guidance and to offer a
framework to practitioners to support the assessment process and provide some consistency in
assessment within the OH Team. It is not intended to be prescriptive.
Who would use this process?
It is intended for use by OH Nurses/OH Advisors within the Occupational Health Team
Does this process relate to a Policy or Local operating procedure?
It relates to the Local Operating Procedure for assessment of student health care workers.
The process:
During the student face to face pre-training health assessment both the mental health and physical
health of the student will be discussed. The student may have declared information about their
physical and/or mental health on the questionnaire and the guidance in appendix 1 and/or 2 may be
used to elicit further relevant information as part of the ‘history taking’ process. If the student has
not declared either mental health issues or physical health issues they should be asked if they have
ever suffered with any physical health issues or mental health issues. If they state that they have
experienced physical and/or mental health issues then the guidance in appendix 1 and/or 2 should
be followed.
It is not important in which order the issues are addressed but for the purpose of this process
document mental health is approached first.
If during the assessment process it is felt that the student maybe deemed as disabled under the
terms of the Equality Act 2010, then consideration should be given to highlighting this to
Admission/the Faculty and an entry to this effect made in the Occupational Health records.
If they declare a mental health issues then the questions in appendix 1, tier 2 should be asked and
observations made recording responses to questions in the OH records. Appendix:
Questions
1.
2.
3.
4.
5.
What was it
When was it?
Are you currently suffering from any symptoms?
How was it treated?
Are you currently being treated? If so is it ongoing?
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6. Why did it occur?
7. Are there any effects on activities of daily living?
Observations
Eye contact
Anxiety/agitation
Personal Care
Confidence
Rational thinking
General demeanour
If it is felt that insufficient information is available to provide health clearance then the questions at
tier 3 should be applied.
Questions
1.
2.
3.
4.
Have you ever had thoughts of harming yourself or others? If so how?
Do you have an eating disorder? If so what type and when?
Is you BMI 16 or below?
Do you have suicidal thoughts? Have you made plans or attempted suicide? If so how and
when?
5. Have you ever been hospitalised due to mental illness? Was this voluntarily or not?
6. Are you/have you received any therapies? If so was this from a counsellor, psychotherapist,
psychologist or psychiatrist? How long and when?
7. Are you/have you received medication? If so what medication/dose, how long for and is this
ongoing?
If it is felt that at stage 3 a clear opinion on medical fitness for practice placement cannot be made
then tier 4 should be progressed to, where a number of options are available to the practitioner.
They may wish to undertake one or more options. The options are discuss the case with the OH
team to seek their opinion; discuss the case with the OHP to seek his opinion; obtain a medical
report; refer the student to the OHP for assessment and opinion upon health clearance.
At any time during stage 2 or 3 the practitioner may wish to progress straight to stage 4, if the
student is uncooperative or unable to provide the information required the practitioner again may
wish to progress to stage 4.
If they declare a physical health issues then the questions in appendix 2, tier 2 should be asked and
observations made recording responses to questions in the OH records:
Questions
1.
2.
3.
4.
What was it
When was it?
Are you currently suffering from any symptoms?
How was it treated?
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5. Are you currently being treated? If so is it ongoing?
6. Why did it occur?
7. Are there any effects on activities of daily living?
Observations
If it is felt that insufficient information is available to provide health clearance then tier 3 should be
applied, assessing functional capability using the assessment tool:
Assessment tool – work ability index
If it is felt that a clear opinion on medical fitness for practice placement cannot be made then tier 4
should be progressed to, where a number of options are available to the practitioner. They may wish
to undertake one or more options. The options are discuss the case with the OH team to seek their
opinion; discuss the case with the OHP to seek his opinion; obtain a medical report; refer the student
to the OHP for assessment and opinion upon health clearance.
At any time during stage 2 or 3 the practitioner may wish to progress straight to stage 4, if the
student is uncooperative or unable to provide the information required the practitioner again may
wish to progress to stage 4.
Responses to questions and information gathered should be documented in the Occupational Health
records in line with the OH department Local operating procedure for record keeping.
Documents referred to:
Mental health and employment in the NHS DH 2008
Medical fitness nurse and Midwife training HEOPS (Higher Education Occupational
Physicians/Practitioners date unknown
Medical student’s standards of medical fitness to train HEOPS (Higher Education Occupational
Physicians/Practitioners date unknown
Teacher training Agency - Able to Teach April 2004
Appendices:
Appendix 1 – Aide memoire – mental health
Appendix 2 – Aide memoire – physical health
Appendix 3 – ‘Issues for consideration’ – mental health assessment
Appendix 4 – Work ability index
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Appendix 1 Aide memoire – mental health
Tier 1
Have you ever suffered with any mental health problems declared or not?
If response is yes move to tier 2 of the assessment
Tier 2 – Mental health
Observations
Questions
1.
2.
3.
4.
5.
6.
7.
What was it
When was it?
Are you currently suffering from any symptoms?
How was it treated?
Are you currently being treated? If so is it ongoing?
Why did it occur?
Are there any effects on activities of daily living?






Eye contact
Anxiety/agitation
Personal Care
Confidence
Rational thinking
General demeanour
If it is felt that further information is required to enable full assessment move to tier 3 of the
assessment
Tier 3-mental health
Questions
1.
2.
3.
4.
Have you ever had thoughts of harming yourself or others? If so how?
Do you have an eating disorder? If so what type and when?
Is you BMI 16 or below?
Do you have suicidal thoughts? Have you made plans or attempted suicide? If so
how and when?
5. Have you ever been hospitalised due to mental illness? Was this voluntarily or not?
6. Are you/have you received any therapies? If so was this from a counsellor,
psychotherapist, psychologist or psychiatrist? How long and when?
7. Are you/have you received medication? If so what medication/dose, how long for
and is this ongoing?
If it is felt that a clear opinion on medical fitness for practice placement cannot be made move to
tier 4 of the assessment
Tier 4 – mental health
One or more of the following options may be taken
 Team discussion – Nurses
 Discussion of case with the OHP
 Obtaining a medical report
 Refer to OHP for assessment
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
No further action at present
Appendix 2- Aide Memoire Physical health
Tier 1 Physical health
Have you ever suffered with any physical health problems declared or not?
If response is yes move to tier 2 of the assessment
Tier 2 – physical health
Observations
Questions
1.
2.
3.
4.
5.
6.
7.
What was it
When was it?
Are you currently suffering from any symptoms?
How was it treated?
Are you currently being treated? If so is it ongoing?
Why did it occur?
Are there any effects on activities of daily living?




Gait
Use of mobility aids
Hear conversational
speech?
Evidence of visual
impairment
If it is felt that further information is required to enable full assessment move to tier 3 of the
assessment
Tier 3-physical health
Assessment tool – work ability index (see appendix 4)
If it is felt that a clear opinion on medical fitness for practice placement cannot be made move to
tier 4 of the assessment
Tier 4 – physical health
One or more of the following options may be taken





Team discussion – Nurses
Discussion of case with the OHP
Obtaining a medical report
Refer to OHP for assessment
No further action at present
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Appendix 3 – Issues for consideration – mental health assessment

Consider nature, duration and severity of condition including level of awareness/ insight into
condition – lack of self awareness increases risks

When was the client last treated?
o Community Mental Health Team
o Therapy
o Where they recently discharged
o Consider what medication past and current
Risks are increased if currently or recently engaged with services




What has the client done in recent years?
o Where they actively engaged in study
o Where they holding down work
o Are there any gaps in activity/periods of inactivity
Mental Health robustness is needed to work/study
Look for evidence of productivity in the last year

Patterns of illness
o Recurrent illness or one off episode?
o Circumstances of illness
 Stress
 Drugs
 Transition
o Any evidence of non-compliance
o Lifestyle - ? abusive partner

Insight into illness
o Recognition of patterns
o Efforts to change patterns
o Evidence of insight into vulnerability to relapse
o Do they acknowledge they need support?
o Have they engaged with support services
Look for evidence of insight into condition

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
Domestic situation
o
o
o
o

What support network do they have (if any)
 Friends
 Family
Any financial pressures
Evidence that they can form appropriate relationships
Family history of mental illness
Triggers
o Are there any identifiable triggers for episodes of mental ill health /relapses
Appendix 4– Work ability index
1. Current work ability compared with the lifetime best
Assume that your work ability at its best has a value of 10 points.
How many points would you give your current work ability?
(0 means that you cannot currently work at all)
unable to work at present
0
1
work ability at present
2
3
4
5
6
7
8
9
10
2. Work ability in relation to the demands of the job
How do you rate your current work ability with respect to the physical demands of your
work?
very good
5
rather good 4
amoderate 3
rather poor 2
very poor
1
How do you rate your current work ability with respect to the mental demands of your work?
very good 5
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rather good 4
amoderate 3
rather poor 2
very poor
1
3. Number of current diseases diagnosed by a physician
In the following list, mark your diseases or injuries. Also indicate whether a physician has
diagnosed or treated these diseases. For each disease, therefore, there can be 2, 1, or no
alternatives circled.
Injury from accidents
01 back
02 arm/hand
03 leg/foot
04 other part of body, where and
what kind of injury?
Yes - own opinion
Yes – Physician’s opinion
2
2
2
2
1
1
1
1
2
1
2
1
2
1
2
1
2
2
1
1
2
1
2
1
2
1
2
1
...............................................
Musculoskeletal disease
05 disorder of the upper back or
cervical
spine, repeated instances of pain
06 disorder of the lower back,
repeated instances of pain
07 (sciatica) pain radiating from
the back into the leg
08 Musculoskeletal disorder
affecting the limbs (hands, feet),
repeated instances of pain
09 rheumatoid arthritis
10 other musculoskeletal disorder,
what?
..............................................
Cardiovascular diseases
11 hypertension (high blood
pressure)
12 Coronary heart disease, chest
pains during exercise (angina
pectoris)
13 coronary thrombosis,
myocardial infarction
14. cardiac insuffi ciency
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15 other cardiovascular disease,
what?
2
1
2
1
2
2
2
2
2
2
1
1
1
1
1
1
2
1
2
1
2
2
1
1
2
1
2
1
2
2
2
2
2
2
1
1
1
1
1
1
2
2
1
1
................................................
Respiratory disease
16 repeated infections of the
respiratory tract (also tonsillitis,
acute sinusitis,
acute bronchitis)
17 chronic bronchitis
18 chronic sinusitis
19 bronchial asthma
20 emphysema
21 pulmonary tuberculosis
22 other respiratory disease,
what?
.................................................
Mental disorder
23 mental disease or severe
mental
health problem (for example,
severe
depression, mental disturbance)
24 slight mental disorder or
problem
(for example, slight depression,
tension, anxiety, insomnia)
Neurological and sensory disease
25 problems or injury to hearing
26 visual disease or injury (other
than refractive error)
27 neurological disease (for
example
stroke, neuralgia, migraine,
epilepsy)
28 other neurological or sensory
disease, what?
.................................................
Digestive disease
29 gall stones or disease
30 liver or pancreatic disease
31 gastric or duodenal ulcer
32 gastritis or duodenal irritation
33 colonic irritation, colitis
34 other digestive disease, what?
Genitourinary disease
35 urinary tract infection
36 kidney disease
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37 genitals disease (for example
fallopian tube infection in women
or prostatic infection in men
38 Other genitourinary disease,
what?
Skin diseases
39 allergic rash, eczema
40 other rash, what
41 other skin disease, what?
Tumour
42 benign tumour
43 malignant tumour (cancer),
where?
2
1
2
1
2
2
2
1
1
1
2
2
1
1
2
2
2
2
1
1
1
1
2
2
1
1
2
1
2
1
.................................................
Endocrine and metabolic diseases
44 obesity
45 diabetes
46 goiter or others thyroid disease
47 other endocrine or metabolic
disease,
what?
.................................................
Blood diseases
48 anemia
49 other blood disorder, what?
..................................................
Birth defects
50 birth defect, what?
..................................................
Other disorder or disease
51 What?
..................................................
4. Estimated work impairment due to diseases
Is your illness or injury a hindrance to your current job?
Circle more than one alternative if needed.
There is no hindrance/I have no diseases
6
I am able to do my job, but it causes some symptoms
5
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I must sometimes slow down my work pace or change
4
my work methods
I must often slow down my work pace or change my work methods
3
Because of my disease, I feel I am able to do only part-time work
2
In my opinion, I am entirely unable to work
1
TOTAL SCORE
Evaluation
Completion of the questionnaire results in a figure or score which lies between 7 and 49. The figure
describes the current work ability of the respondents and, at the same time, permits forecasts to be
made of the health risk. A high value indicates a good work ability, a lower value an unsatisfactory or
jeopardised work ability. Depending on the level of the figure it is recommended to maintain,
support, improve or reinstate the work ability
Result
2-27
28-36
37-43
44-49
Category
poor
medium
good
Very good
Work ability action
Reinstate work ability
Improve work ability
Support work ability
Maintain work ability
Note: low work ability values indicate incongruity between the work demands and the work
capability of the employee.
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Occupational Health
Department
79
Appendix 21
IMMUNISATION RECORD
Date of Birth:
Click here to enter a date.
Please keep this immunisation information in a safe place. You may be required to
produce this information on clinical placement if applying for a post as a health care
worker during your training and at the end of your training when applying for
employment.
Name:
Date immunised/tested
Immunity status/blood test
Hepatitis B 1
Outcome/results
Hepatitis B 2
Hepatitis B 3
Hepatitis B Booster
Hepatitis B surface antibody level
>100 iu/l
Hepatitis B surface antigen level
N/A
MMR 1
MMR 2
Varicella – History of infection
Yes
Varicella 1
Varicella 2
Tuberculin skin test
BCG
Scar present?
Yes
Rubella antibody
N/A
Measles antibody
N/A
Varicella antibody
N/A
Other
Cleared for exposure prone procedure
Signature:
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80
Name:
Designation:
Date:
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Appendix 22
Flow Chart pre-registration health assessment FHSC students
Faculty send information pack to students
with the health questionnaire asking them
to contact OH for an appointment
Admissions send list of students
for health assessment to OH
Student contact OH to make an
appointment for face to face assessment
Health questionnaire completed by student and sent to OH
Advised on student
system clearance given
Yes
Pre-training health assessment (either EPP
or non EPP) undertaken face to face by a
nurse prior to registration *See note
below
Health clearance given?
Report where required
(midwives and students with
health issues etc..) sent to
admissions, disability tutor and
student
No
More information required?
*Note: If a student is
assessed/ cleared after
course registration we
don’t advise via student
system. A report of health
will be completed for all
students and sent to the
Intake Leader, Disability
Tutor and the Student.
Interim report sent to admissions
Yes
Refer case to OH Physician
Obtain a medical report
Health clearance given?
Yes
No
Final report of health to
admissions, disability tutor and
student
More information required?
Yes
Advised on student system clearance given
No
Refer case
to OHP
The Faculty
may wish to
share
information
with practice
areas.
OHP/ Nurse
sends report to
admissions and
the student
Health clearance given?
Yes
-------
No
Report sent to admissions,
disability tutor
and student
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82
Appendix 23
Flow chart for referral of health care students during training
Health concerns may have been raised
by the trust via the ‘individual student
health case tracking’ form. The FHSC
may seek OH advice or may wish to
refer the student
------ Referral form completed by HOD
and sent to OH
Referral is triaged
Remote advice is offered on the case
without the student being seen
Appointment offered to student
Face to face Nurse assessment
undertaken – occasionally the
student may be assessed by the
OHP at this stage
Review required?
More information required?
Yes
No
Medical report requested with consent
Case passed to OHP
More information required?
Yes
No
Interim report sent to HOD
Refer to OHP
Report sent to HOD and student
The Faculty may
wish to share
information with
practice areas
----------
Case closed
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Appendix 24
Flow chart pre-registration health assessment HYMS students
HYMS send health
questionnaire to student
Student completes and
returns to OH Department
Questionnaire is screened
by OH Practitioner
More information required?
No
Yes
More information requested
HYMS advises OH which student will
attend York and which will attend Hull
HYMS liaise with OHD and
appointment slots allocated for
each Hull student after registration
date. HYMS advise the students of
their appointments
Health questionnaires for York students
sent to OHD York NHS Trust for
assessment. No further involvement
Following questionnaire screening once student identified as
attending Hull Student does the student need to been seen
early prior to registration?
Yes
No
OHD make direct contact with the student and
offer additional early appointment. HYMS are
informed
More information required?
Student assessed face to face after registration
Health clearance given?
No
Yes
Yes
Interim report to HYMS
Refer case to/ discuss case with OHP
Report of health to
HYMS and student
Obtain a medical report
Health clearance given?
No
Yes
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More information required?
Yes
No
Case closed
OHP/OH Nurse sends report of health
to HYMS and student
HYMS may wish to
----- share information
with practice areas
Appointment with OHP
Health clearance given?
Yes
No
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Appendix 25
Flow chart - health assessment visiting international students - FHSC
Contact made by FHSC requesting
assessment of an international student/s
Faculty make an OH appointment/s for the
student and advise the student directly of
the appointment date and time
Faculty send health questionnaire to the
students asking them to complete and return to
the OH Department
Health questionnaires are screened if required
further information is requested
Student is assessed face to face in OH Department
Health clearance provided?
Yes
Are any vaccinations
recommended?
No
Interim report of health sent to team
member arranging assessment
No
Further information required and/or further
assessment required?
Yes
Funding from FHSC for
vaccinations sought and approved
Vaccination provided?
No
Yes
Further information
obtained/OHA review/OHP
assessment
Yes
Health clearance provided?
Faculty advised of
students immune
status and
recommendations for
practice placement
made
No
No
Yes
Report of health sent to FHSC team member
arranging the assessment
----
The Faculty may wish to
share information with
--practice area
Case closed
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Occupational Health
Department
Appendix 26
Are you fit to Nurse?
Information for prospective nursing students about health
assessment
Nursing, in common with other occupations, makes physical and emotional demands which
require an appropriate level of health and fitness. A number of hazards are associated with
working in the healthcare industry. Nurses can be protected against some of them –
infection, for instance; others may worsen existing medical conditions such as eczema.
Although there are actually very few health conditions which would automatically exclude
entry to or progression within nursing, you will be required to participate in a health
assessment before starting your nursing education.
The purpose of this is to protect:



patients and the public
your own health and safety
other colleagues you may be working with
Common methods of undertaking this assessment include:



a health declaration form you have to complete yourself and
an interview with an occupational health nurse and/or
a medical examination by a qualified occupational physician
In practical terms, the areas covered will include:



your vaccination history
your previous medical history
any recent or current treatment
Recommendations for acceptance onto the nurse education programme will be made to the
department of nursing which will confirm your placement.
The information you supply to the occupational health department remains confidential to
that department and only a recommendation on fitness will be made to the university.
The vast majority of health assessments prior to nurse education are satisfactory. If the
recommendation is unfavourable, the occupational health physician will discuss this with
you.
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87
Occupational Health
Department
Appendix 27
HEALTH CARE STUDENTS PRE-COURSE HEALTH ASSESSMENT
INCLUDING NURSING, MIDWIFERY, ODP AND MEDICAL
STUDENTS
Purpose.



To ensure as far as is practicable, the student is not a potential risk to their
patients.
That working in a clinical environment /patient contact will not pose a risk to the
student’s health and wellbeing physically and mentally.
To meet firstly with the department of health guidance for immunisation for health
care workers (green book), and secondly ‘Health clearance for tuberculosis,
hepatitis B, hepatitis C and HIV: New healthcare workers’. Please see references
below. Guiding principles from other relevant documents are also considered- for
example, NMC good health good character: Guide for educational institutions.
Screening Process.

The student’s general health is assessed from the health questionnaire and where
required face to face assessment. Medical reports will be obtained if any concerns in
relation to both physical and/or mental health that may have an impact in the clinical
environment. Some students will be referred to the Occupational Health Physician
(OHP). Faculty will be kept informed at each stage.
Immunisation screening:



MMR – The student must provide evidence of two MMR vaccinations, if not the
student is asked to obtain them from their GP, if unable to do so MMR vaccination
will be offered by OH. If the student is an international student a blood test will be
undertaken in addition to evidence of immunity being supplied.
Varicella – A definite history of chicken pox is evidence of immunity, however, if an
unsure history, midwives, child branch or international students a blood test is carried
out routinely. If negative result two varicella vaccinations will be offered through OH.
TB – All students are asked if they have had a BCG in childhood a BCG scar or
written evidence is sufficient. If a student has not had a BCG in childhood or is an
international student from a high risk country they will be offered screening,
mantoux/BCG as relevant by OH.
Hepatitis B – A full course of Hepatitis B and blood test will be offered (including
boosters and second courses where indicated) by OH to the student, and is
scheduled into the programme.
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88
Additions for students performing exposure prone procedures (EPP) Midwives, ODP
and Medical students.

Student will be tested for blood borne viruses (BBV’s) specifically: HIV, Hepatitis C
and Hepatitis B surface antigen and will be identified validated samples.
All Students will only be cleared for clinical practice when we have all the information
requested including evidence of MMR vaccinations or a positive blood test for measles
/rubella. In the case of EPP work the student will not be cleared until the BBV results are
available.
Note: Please see appendix 1 and 2– these documents are included in the student health
questionnaire for the information of the prospective student. They are asked to retain this
document. Please also see appendix 3 provided to nursing students.
References:Department of Health (2007) Health clearance for tuberculosis, hepatitis B, hepatitis C and
HIV: New healthcare workers.
http://www.dh.gov.uk/en/Publichealth/Communicablediseases/HepatitisB/HepatitisBgenerali
nformation/index.htm
Department of Health (2006) The Green Book Immunisation against infectious disease.
London. Updates on
http://www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/DH_409725
4
Nursing and Midwifery Council (NMC):2008 Good Health Good Character: Guide for
educational institutions
http://www.nmc-uk.org
Health Professions Council (HPC): Guidance on health and character http://www.hpc-uk.org
General Medical Council (GMC): Medical Students Professional Values and Fitness to
Practice
http://www.gmc-uk.org
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89
APPENDIX 1 – Student to retain
Operating Department Practitioners, Nurses and Midwives
The attached questionnaire is intended to support the health assessment process. In a small
minority of cases health clearance may be given based upon the information in the health
questionnaire; however the majority of health care students will need to attend an
Occupational Health appointment to complete the assessment process.
Health care workers including student Nurses, Operating Department Practitioners (ODP)
students, Midwifery students and Medical students need a high standard of physical and
mental fitness to enter and remain in the health care worker profession. Different groups of
health care workers are governed by their relevant professional body, the healthcare worker
medical fitness standards are however similar. In addition to the governing professional
bodies the Department of Health sets out clear health criteria for health care workers.
In relation to the health assessment process to gather all the information we require to offer
a health opinion we may take a number of options these include: obtaining with consent a
medical report, assessment by an Occupational Health Nurse, assessment by an
Occupational Health Physician, referral to a specialist for assessment with report.
Health care workers can be divided into two subgroups those undertaking exposure prone
procedures (EPP) and those not undertaking EPP. Those undertaking EPP require
‘enhanced’ health clearance and include Midwives, ODP’s and Medical students
Your health assessment will be completed as quickly as possible but we cannot guarantee
completing the health assessment process prior to your preferred registration date, this will
depend upon a number of factors including when you contact us to arrange an appointment,
whether the questionnaire is complete, whether you require referral to a Physician or
whether we need to obtain a medical report. Registration onto a course however is a
decision for the faculty and not Occupational Health.
Relevant documents:
Department of Health 2007. Health clearance for tuberculosis, hepatitis B, hepatitis C and
HIV
Nursing and Midwifery Council 2008 Good Health Good Character: Guide for educational
institutions
Health Professions Council: guidance on health and character
College of Operating Department Practitioners: student standards
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90
APPENDIX 2 – Student to retain
Medical students
The attached questionnaire is intended to support the health assessment process. Medical
students will need to attend an Occupational Health appointment with an Occupational
Health Nurse to complete the assessment process.
Health care workers including student Nurses, Operating Department Practitioners (ODP)
students, Midwifery students and Medical students need a high standard of physical and
mental fitness to enter and remain in the health care worker profession. Different groups of
health care workers are governed by their relevant professional body, the healthcare worker
medical fitness standards are however similar. In addition to the governing professional
bodies the Department of Health sets out clear health criteria for health care workers.
In relation to the health assessment process, to gather all the information we require to offer
a health opinion, we may take a number of options these include: obtaining with consent a
medical report, assessment by an Occupational Health Physician, referral to a specialist for
assessment with report.
Health care workers can be divided into two subgroups those undertaking exposure prone
procedures (EPP) and those not undertaking EPP. Those undertaking EPP require
‘enhanced’ health clearance and include Midwives, ODP’s and Medical students.
All Medical students are health assessed after registration. Appointments will be assigned to
you by HYMS to take place during October. Health questionnaires are screened prior to your
assessment and where appropriate further information obtained. Your health assessment
will be completed as quickly as possible however the length of time taken to offer a health
opinion to HYMS depends on a number of factors including whether the health questionnaire
is complete, whether you require referral to an OH Physician or whether we need to obtain a
medical report.
You will be copied into the report of health sent to HYMS following completion of your health
assessment.
Relevant documents:
Department of Health 2007. Health clearance for tuberculosis, hepatitis B, hepatitis C and
HIV
General Medical Council: Medical Students Professional Values and Fitness to Practice
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91
APPENDIX 3
Are you fit to Nurse?
Information for prospective nursing students about health
assessment
Nursing, in common with other occupations, makes physical and emotional demands which
require an appropriate level of health and fitness. A number of hazards are associated with
working in the healthcare industry. Nurses can be protected against some of them –
infection, for instance; others may worsen existing medical conditions such as eczema.
Although there are actually very few health conditions which would automatically exclude
entry to or progression within nursing, you will be required to participate in a health
assessment before starting your nursing education.
The purpose of this is to protect:



patients and the public
your own health and safety
other colleagues you may be working with
Common methods of undertaking this assessment include:



a health declaration form you have to complete yourself and
an interview with an occupational health nurse and/or
a medical examination by a qualified occupational physician
In practical terms, the areas covered will include:



your vaccination history
your previous medical history
any recent or current treatment
Recommendations for acceptance onto the nurse education programme will be made to the
department of nursing which will confirm your placement.
The information you supply to the occupational health department remains confidential to
that department and only a recommendation on fitness will be made to the university.
The vast majority of health assessments prior to nurse education are satisfactory. If the
recommendation is unfavourable, the occupational health physician will discuss this with
you.
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92
Occupational Health
Department
Appendix 28
Customer questionnaire following referral of health care students to the Occupational Health
Department
In order to ensure that we continue to provide a high level of service, we would very much like you to take a few
minutes to complete this short questionnaire. The information you provide is important to us and will be held by
the OH Department in the strictest confidence. Thank you in anticipation for your time.
Not applicable
Very dissatisfied
Dissatisfied
Neither satisfied nor
Dissatisfied
Satisfied
How did you feel about the following aspects of the service?
Very satisfied
1)
The user-friendliness of the referral process
The response time following submission of your referral
The length of time your student waited for an appointment
The response time of the report following the appointment
The quality of the recommendations and guidance you received
The way your questions were answered
The quality of the contact with the OH Department during the referral
process.
The usefulness of the referral overall
2) Overall, how would you rate the quality of the service provided to you?
Excellent
Very good
Quite good
Neither good nor Quite poor
Very poor
poor
Totally
unacceptable
3)
Which Occupational Health Practitioner dealt with your referral? Please give name ................................
4)
Please enter any other comments you have about the service in the box below
If you have a query and would like us to contact you, please provide your name and telephone number
Your Name
Telephone number
Thank you. Please hand or post the completed questionnaire to the occupational health department
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93
Occupational Health
Department
Appendix 29
Student satisfaction questionnaire – End of year one, FHSC
Occupational Health Department
In order to ensure that we continue to provide a high level of service, we would very much like you to take a few
minutes to complete this short questionnaire. The information you provide is important to us and will be held by
the OH Department in the strictest confidence. Thank you in anticipation for your time.
Not applicable
Very dissatisfied
Neither satisfied nor
Dissatisfied
Dissatisfied
Satisfied
How did you feel about the following aspects of the service?
Very satisfied
1)
The booking process and availability of appointments
The time you had to wait upon arrival to see the practitioner
The practitioner’s manner and professionalism
The amount of privacy and dignity you had
Your confidence in disclosing personal information
The way your questions were answered
The quality of any information received (i.e. test results)
2) Overall, how would you rate the quality of the service provided to you?
Excellent
Very good
Quite good
Neither good nor Quite poor
Very poor
poor
3)
Totally
unacceptable
Please enter any other comments you have about the service in the box below
If you have a query and would like us to contact you, please provide your name and telephone number
Your Name
Telephone number
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94
Occupational Health
Department
Appendix 30
Customer satisfaction questionnaire FHSC – end of year one
Occupational Health Department
In order to ensure that we continue to provide a high level of service, we would very much like you to take a few
minutes to complete this short questionnaire. The information you provide is important to us and will be held by
the OH Department in the strictest confidence. Thank you in anticipation for your time.
Not applicable
Very dissatisfied
Dissatisfied
Neither satisfied nor
Dissatisfied
Satisfied
How did you feel about the following aspects of the service?
Very satisfied
1)
The quality of communication from the OH Department i.e. the face-toface or telephone contact.
The way your questions were answered.
The quality of the recommendations and guidance you received.
The usefulness of information received.
The efficiency of the interaction of the student process i.e the pre
planned clinic appointment system.
2)
Excellent
3)
Overall, how would you rate the quality of the service provided to you?
Very good
Quite good
Neither good nor
poor
Quite poor
Very poor
Totally
unacceptable
Please enter any other comments you have about the service in the box below
If you have a query and would like us to contact you, please provide your name and telephone number
Your Name
Telephone number
Thank you. Please hand or post the completed questionnaire to the occupational health department
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95
Occupational Health
Department
Appendix 31
Hull York Medical School (HYMS) – Referral to Occupational Health form
For completion by the Associate Dean for Students. Please complete and return this form to
the Occupational Health department for HYMS Students you wish to refer. Upon receipt of
this completed form an appointment will be offered to the student.
Section 1. Associate Dean for Students details
Associate Dean for Students Name
Contact details
Section 2. Student details
Student Name
Cohort
Section 3 The health issue
3a Please briefly outline the health issue – use additional sheet if required
3b Please outline your concerns about the health issue in relation to clinical practice
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Section 4.Actions taken
Please specify what actions have taken place to date to manage this case
Section 5. Information required
Please specify here what information your require from OH and the questions you would like
addressed
Section 6.
Associate Dean for Students Signature
Date
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Appendix 32
Health Care Students (FHSC/HYMS) Vaccination programme – Flow Chart
Student registers on course
No
Vaccination required?
Appointment offered at TB clinic. Clinics prearranged with Faculty/School. Appointments
sent to student by OH by letter
Yes
TB Screening/vaccination?
Hepatitis B Vaccination?
Appointment offered at Hepatitis B clinic.
Clinics pre-arranged with Faculty/School.
Faculty/School send first appointment to
student. Subsequent Hep B appointments
arranged by OH directly with student
MMR Vaccination?
Appointment date for MMR vaccination
arranged directly with student with
consideration of other vaccinations being
received
Varicella Vaccination?
Appointment date for Varicella vaccination
arranged directly with student with
consideration of other vaccinations being
received
Student declines vaccination
Vaccination programme complete?
Yes
No
If failed to undergo/complete TB, MMR
or Varicella vaccination programme
Faculty/school informed and
recommendations made regarding
practice placement
Student vaccination record completed
and sent by e-mail to students, copy put
in OH records
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Case closed
98
Occupational Health
Department
Appendix 33
Interim Statement – Report of Health, HYMS
Student Pre-course Health Assessment
This interim report is provided to the University to advise of the current position regarding the
health assessment process for the student named below
To: HYMS, Associate Dean for students and student named below
Student Full Name:
DOB
Course/Cohort:
The above named student has undergone – please delete *:
Health questionnaire assessment
*Yes/No
Health screening
* Yes/No
Medical assessment
* Yes/No
The current situation – please delete those not applicable:
OH are awaiting requested medical information
Further assessment is required – an appointment has been sent to the individual
by the team
Specialist assessment is recommended and the OH department will facilitate this
PLEASE NOTE: The pre-course health assessment process has not yet been completed.
You will receive a ‘report of health’ when the process is complete
Remarks/ Recommendations:
Name
Signature
Title
Date
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Occupational Health
Department
Appendix 34
Report of Health – Student Pre-course Health Assessment, HYMS
This report of health provides an opinion to the University about any health/disability issues
in relation to ‘fitness to practice’ on practice placement. The University may wish to share
this information with a practice placement provider.
To: HYMS, Associate Dean for Students and, Student named below
Student full name:
DOB:
Course/Cohort:
The above named student has undergone – please delete *:
Health questionnaire assessment
* Yes/No
Health screening
* Yes/No
Medical assessment
* Yes/No
Opinions offered – please delete whichever statements are not relevant:
The above student has been provided with health clearance for the above course
The above student has not been provided with health clearance for the above
course
Health clearance given to undertake exposure prone procedure work
Yes/No/Not Applicable
Equality Act 2010
- is likely to apply at this stage
- is not likely to apply at this stage
-applicability is unclear at this stage
Remarks/Recommendations – including recommendations on obstacles to practice, reasonable adjustment
for practice placement and any further OH action:
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Name:
Signature:
Title:
Date:
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Occupational Health
Department
Appendix 35
CONSENT FORM – PRE-TRAINING ASSESSMENT, HYMS
Personal Details
Surname:
First Name(s):
Date of Birth:
Address:
Post Code:
Consent for a report to be sent to HYMS by the Medical School’s health advisor
Following your pre training health assessment by an OH Team Member, it is necessary for a
report outlining your medical condition to be sent to HYMS - Associate Dean for Students.
The focus of the report will be to provide information to assist the Medical School in
supporting you whilst on practice placement and will be briefly outlined to you prior to the
end of your assessment. The Medical School may need to share this information with the
practice placement provider. If you withhold consent this may impact on practice placement,
it is possible that you may be excluded from clinical practice. A copy will be sent to you.
I do / do not consent for this information to be disclosed
Signed: ……………………………………………… Date:
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Appendix 36
Flow chart - referral of Medical (HYMS) Students during training
Referral form completed by Associate
Dean Students and sent to OH
Referral is triaged
Remote advice is offered on the case
without the student being seen
Appointment offered to student. Associate
Dean Students advised of appointment
Face to face Nurse assessment
undertaken – occasionally the
student may be assessed by the
OHP at this stage
Review required?
More information required?
Yes
No
Medical report requested with consent
Case passed to OHP
More information required?
Yes
No
Interim report sent to
Associate Dean Students
Refer to OHP
HYMS may wish to share information with
the practice area
Report sent to Associate Dean Students
and the student
-----
Case closed
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Appendix 37
Faculty of Health and Social Care (FHSC)
Confidential Student Health Case Tracking Form
This form is to be used in all cases where concerns arise about a student’s (registered in the
FHSC) health status whilst on practice placement. A copy of the form will be kept in the
student’s file in the Faculty. If further health assessment or advice is required a copy will be
forwarded to the University Occupational Health Department.
Students Surname
University Registration Number (if known)
Forenames
Programme of Study
Year
Semester
Name of Trust / Placement provider
Name of placement: ward/department/service
Brief description of incident / injury/ health concern
Brief overview of treatment / action taken – including assessment by the Trust OH Department
Any follow up required / recommended – brief description
Person completing form:
Name (please print):..............................................Signature.....................................................
Designation
Date
Contact no Tel:
Please return to:
Head of Department (see right)
Faculty of Health and Social Care
University of Hull
HU6 7RX
Email:
For Adult Nursing and Midwifery Students;
Department of Nursing and Midwifery
For Mental Health, Learning Disability, Child, Community
Nursing Students (DN, HV etc):
Department of Community Health and Social Care
For Operating Department Practitioner Students:
Department of Health Professional Studies
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Received by name:
Date:
Copy to file by name:
Date:
Copy to Occ Health by name:
Date
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Occupational Health
Department
Appendix 38
Consent for obtaining immunisation related information
Section 1 – Personal details (to be completed by the individual)
Full name:
Dob:
Section 2 – Consent (to be completed by the individual)
I hereby consent to the University of Hull Occupational Health Department obtaining immunisation
related information as detailed below (section 3). Please provide the name and address of the
hospital or other organisation that can be contacted to obtain information
Name and address or hospital/organisation:
Signature:
Date:
Section 3 – Information required (to be completed by the Hospital/organisation)
The above named individual has applied to work or study at the University Of Hull. They have advised
us that you will have immunisation related information pertaining to them. In order to avoid duplication
I would be most grateful if you would supply any information you have as detailed below. Please
could you include copies of any laboratory reports available?
Immunisation/test
Date
Outcome/Result
Comments
Grade /measurement
Heaf/Mantoux test
BCG vaccination
MMR 1
MMR 2
Rubella
Rubella titre
Measles Immunity
Varicella Immunity
Varicella vaccination
Hepatitis B vaccination
Scar visible
Yes / No
1.
2.
1.
2.
3.
Hepatitis B Booster
Hepatitis B antibody
Other (please specify)
Hepatitis B Surface Antigen
Hepatitis C
HIV
Please return this information to the: Occupational Health Department
University Of Hull
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IVS YES/NO
IVS YES/NO
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Hull HU6 7RX
United Kingdom. E-mail- occupationalhealth@hull.ac.uk
Many thanks for your assistance
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