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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. The information on this form remains confidential (subject to the Data Protection Act) within the Occupational Health service and any recommendations given to managers with regards to adjustments or support in the workplace will be after your explicit consent is sought.

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. If you are a new starter into a specialist role which involves EPP (Exposure Prone Procedures) i.e. surgeons – including training rotations, dental staff, theatre staff, midwives and doctors and nurses in Accident and Emergency Departments, you will be required to provide evidence of freedom from infection from blood borne viruses.  You will not be permitted to start your role until we have this information. These tests can be arranged via the Occupational Health Department.

All staff should sign a consent form to enable us to request immunisation details from your previous Occupational Health Provider. If you already have this information or copies of any blood tests that could be relevant to your role, these should be either emailed or posted to the addresses below. Should you need a consent form to sign, please contact the Department at your earliest convenience. We ask for your NHS Number, as this needs to be put on any requests for blood tests that we take. This information can be obtained from your GP practice or on any letter/medical card from hospitals etc.

Once you have completed the form it will automatically be emailed through to the Occupational Health Department. If you have not completed all the mandatory fields it will not be accepted. Upon receipt of this form it will be assessed by our nurses. If you need to be seen in department we will then write to you. If you require any assistance or support in completing this form, please contact a member of the Occupational Health Team, by telephoning the Department on 01422 222037. Any copies of blood reports or vaccine information can be posted or emailed to: 

The Occupational Health Department

Calderdale Royal Hospital



HX3 0PW  

Email to: