University of Reading Assessment for Working with Human Volunteers
This form is confidential to Health Management Ltd. It should be completed by the Manager
responsible for the employee. It should then either be faxed to Health Management Ltd on 0845 504
1066 or posted directly to The Clinical Services Team, Health Management Ltd, Ash House, The
Broyle, Ringmer, East Sussex, BN8 5NN or emailed to team.s2@healthmanltd.com
HR / Manager Details
Name………………………………………………………………………. (BLOCK CAPITALS PLEASE)
Title…………………………………………………………………………………………………………..
Dept / School …………………………………………………………………..…………………………..
Directorate / Faculty …………………………………………………………..…………………………..
Address for us to reply to
…………………………………..…………...…………………………..
Contact telephone number ……………………………………………………………………………….
Contact Email …………………..………………………………………………………………………….
HR Partner to be copied on appointment ………………………………………………………………
Cost Centre…………………………………………………………………………………………………
Employee Details
Employee Name:
Date of Birth
Place of Birth
Company / Organisation
Job Title
Department / School
Directorate / Faculty
Employee’s home address:
Email Address:
Contact telephone:
Assessment for Healthcare Workers, University of Reading - Oct 2011
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Please note this form is not appropriate for EPP workers, please contact Health Management if
you require screening and /or advice on EPP workers.
Previous Employment
Job Title
Employer
Location
Dates
1……………………………………………………………………………………………………………………
2……………………………………………………………………………………………………………………
3……………………………………………………………………………………………………………………
Satisfactory documentary evidence consists of a photocopy of a pathology report from a recognised UK
laboratory or an official document issued by an Occupational Health Department or GP practice on
headed paper, signed by a qualified person, giving full details of full name, date of birth, course dates
and vaccination status for:




Hepatitis B
Varicella
Rubella
Measles
That your BCG Scar > 4mm has been seen
PLEASE NOTE THAT WE WILL REQUIRE EVIDENCE FOR ALL OF THE ABOVE IN ORDER TO PROVIDE
CLEARANCE TO WORK AS A HEALTHCARE WORKER
Please complete
Dates/Year
Immunisation History
1
2
3
Booster
Please give the fullest details possible
Tetanus Immunisation
Rubella (German measles) immunisation/MMR
BCG Immunisation (TB)
Measles Immunisation (MMR)
Hepatitis B Immunisation
Chickenpox (VzV) Immunisation
Diphtheria
Polio
Have you had Shingles or Chickenpox
YES / NO
Have you ever had any of the following
tests?
(Please delete as appropriate)
Date
Result
Rubella Antibodies
TB Skin test (Heaf or Mantoux)
Hepatitis B antibodies
Hepatitis B surface antigen
Assessment for Healthcare Workers, University of Reading - Oct 2011
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If you answer yes to any of the questions below please give further details including dates, length
of treatment and time off work in the column.
1.
a)
b)
c)
d)
2.
Do you have any of the following:
Yes
No
From
To
Details
A cough which has lasted for more than 3
weeks?
Unexplained weight loss?
Unexplained fever?
TB or been in recent contact with open TB?
Have you recently arrived or returned to the
UK from another country?
You are reminded that healthcare workers have an ethical and professional responsibility to ensure that
they do not put patients’ safety at risk. The Occupational Health Service will be able to give you
confidential advice regarding any medical condition and its relation to your practice.
I certify that to the best of my knowledge and belief the information given here is true and correct. I also
understand that any deliberate material inaccuracy in the information given may be sufficient grounds for
my contract of employment to be terminated.
I have included documentary evidence of my vaccination status YES
NO
Signed ……………………………………………………………….. Date …………………………………….
Print Name…………………………………………………….
This form should be sent with your completed HM 30 to:The Clinical Services Team, Health Management Ltd, Ash House, The Broyle, Ringmer, East
Sussex BN8 5NN or by fax: 0845 504 1066
Assessment for Healthcare Workers, University of Reading - Oct 2011
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