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Occupational Health — special staff status health declaration

Occupational Health — special staff status health declaration

Confidential medical information.

Form to be submitted at least 2 weeks prior to start date, but do not submit more than 2 months prior to your start date, as we do not have the capacity to hold these longer than this.

This questionnaire must be completed by all visitors entering Health New Zealand | Te Whatu Ora Capital, Coast, Hutt Valley and Wairarapa District premises for professional reasons without a contractual arrangement, for example, visiting medical personnel, clinical observation, and researchers.

All visitors must be sponsored by a senior Health New Zealand | Te Whatu Ora Capital, Coast, Hutt Valley and Wairarapa District staff member. The sponsor is responsible for the visitor while they are at Health New Zealand | Te Whatu Ora Capital, Coast, Hutt Valley and Wairarapa District and must ensure that the visitor complies with all health and safety requirements of Health New Zealand | Te Whatu Ora Capital, Coast, Hutt Valley and Wairarapa District including infection prevention and control.

Section A — visitor details

First names

Last name

Previous name(s)

Date of birth

Gender

Address

Mobile phone number

Personal email address

NHI number (if known)

Purpose of visit — describe in detail the activities or duties you will be undertaking.

Start date

Finish date (maximum time allowed: 1 year)

How long will you be at Health New Zealand | Te Whatu Ora Capital, Coast, Hutt Valley and Wairarapa?

Section B — sponsor's details

Sponsor's name

Sponsor's position

Sponsor's phone number

Section C — visitors who will have patient contact to complete

Health New Zealand | Te Whatu Ora Capital, Coast, Hutt Valley and Wairarapa District expects you to be able to provide (if required for contact tracing) documentation of:

hepatitis B — AntiHBs >20 10iu/L
measles — 2 x MMR vaccination record or serology report
chickenpox — history of disease or 2 x vaccination record
whooping cough (pertussis) — record of vaccination received in the past 10 years.

Section D — declaration statement

Health and Safety and infection control is extremely important with the hospital setting. There is both a higher risk from you possibly exposing others to any infection that you carry and also a higher risk that you may be exposed to an infectious disease from others within the hospital.

Because of this we require an undertaking from you that you will not enter the hospital environment for work purposes or as an observer if you are suffering a potentially contagious disease. The main routes of exposure to an infectious disease are having direct skin to skin contact with other people or via contaminated surfaces, or airborne spread from breathing contaminated air or droplet spread (such as coughing or sneezing).

We therefore require you to agree to this statement that you will not enter the hospital if you have an infectious disease or any symptoms such as fever, cough, cold, skin infection, or skin condition that is causing significant skin flaking. You must also follow any Health and Safety or infection control requirements asked of you by Health New Zealand | Te Whatu Ora Capital, Coast, Hutt Valley and Wairarapa District staff members. If you have any questions or are uncertain then please contact the Occupational Health Nurse for further discussion and advice.