Health at work

Guidance Notes

Please read the following notes carefully before completing the Health at Work Form.

The purpose of this form is to assist the Occupational Health Team to have a better understanding of how any health needs you may have can be supported in the workplace in accordance with the Equality Act 2010 and to provide a basis for maintaining your immunisations in relation to the work you will be doing. 

Processing of Data is necessary for the purpose of preventative or Occupational Medicine, for the assessment of the working capacity of the employee, medical diagnosis, and the provision of care or treatment.  CHFT and the staff Health and Wellbeing Occupational Health Service abide by current data protection legislation (GDPR ; Data Protection Act 2018).  Further details are posted on the trust website and staff intranet, or available from the staff Health & Wellbeing Occupational Health Department. 

Personal health information will remain confidential to the staff Health & Wellbeing service; information shared with managers is expressed in fitness to practice.  Immunisation information and appointments may be shared with managers in order to manage your health & safety in the workplace.

Sections 1 and 3 to be completed by all staff.

Section 2 should be completed if you have answered YES to any of the questions in Section 1.

Section 4 applies only to new starters into specialist roles which involve EPPs (Exposure Prone Procedures) i.e. surgeons - including training rotations; dental staff, theatre staff, midwives and doctors and nurses in Accident & Emergency departments.

Should you wish to discuss completion of this form with a member of the Occupational Health Team, please telephone the Department on 01422222037.

Once you have completed the form, please return it directly to the Occupational Health Department:

By email to: occupational.healthCHTcht.nhsuk

Or by post to:   The Occupational Health Department, Calderdale Royal Hospital, Salterhebble, Halifax, HX3 0PW

Please be aware that this form is best completed on a desktop computer due to the nature of the information you need to provide.

Health at Work Form


Section 1
We will use your contact details to phone, write, e mail or text you on Occupational Health appointments and Occupational Health business. We will not share your contact details outside of the service without your consent. Please advise the service if you wish to amend these details at any time.
Have you worked in the NHS in Calderdale or Huddersfield before?*
Do currently work for the CHFT?*
Have you previously worked for our CHFT?*
Have you previously worked elsewhere for the NHS?*
Do you have any illness/impairment/disability (physical & psychological) which may affect your work?*
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?*
Are you having, or waiting for treatment or investigations at present?*
Do you think you will need any adjustments or assistance to help you to manage your work or your place of work?*
Section 2
Only complete this section if you answered YES to any questions in Section 1.
Section 3a: Tuberculosis
Have you lived continuously in the UK for the last 5 years?*
Have you had the BCG vaccine?*
Have you had the TB infection in the past?*
Have you had any recent close contacts with TB?*
Have you recently had the following?
A cough lasting more than 3 week*
Unexplained weight loss*
Unexpected fever*
Section 3b: Chickenpox
Have you ever had chickenpox or shingles?*
Have you had evidence of immunity (blood test result)?*
Have you had Varicella vaccinations?*
Section 3c: Measles/Rubella
Have you had MR or MMR vaccinations?*
Have you evidence of immunity (blood test results)?*
Section 3d: Hepatitis B
Have you had vaccinations against Hepatitis B?*
Have you evidence of immunity (blood test results)?*
Section 3e
Are you attaching evidence of blood test results/vaccination dates?*
If you were born after a certain date we may be able to get dates that you had certain vaccines from records held with the child health team. To do so we need your consent.*
Section 4
This section relates only to EPP Workers (Exposure Prone Procedure) which includes surgeons – including training rotations; dental, theatre staff, midwives / oncology, doctors and nurses in A&E, who will need Occupational Health screening for communicable diseases/immunisations before starting any EPP duties. All healthcare workers or trainees on placement who perform exposure prone procedures (including all surgeons and surgical specialities, dental, theatre staff, midwives and A&E staff) must demonstrate freedom from infection of Hepatitis B, Hepatitis C and HIV in the form of a blood report from an accredited laboratory, which clearly states to be a “validated sample” as per Department of Health guidelines.

This section relates to all healthcare workers (including EPP workers)
Under Department of Health guidelines, all healthcare workers with clinical contact are screened to ensure they are protected against Hepatitis B, Chickenpox, Measles, Rubella and Tuberculosis (where appropriate)..

The results of these checks must be available before clearance can be authorised for you to undertake exposure prone activities.
I am attaching a good quality copy of my blood test results
I give Permission to approach my previous Occupational Health Department at:
If such evidence cannot be provided, the appropriate checks will be made through the Occupational Health Department. Please contact the Department on 01422 222037 to arrange an appointment.
Please complete the sum below before submitting this form.

Form last reviewed:10/07/18

Form Owner: