Health at work
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
Form last reviewed:10/07/18