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Staff Health Form: - All Fields Are Mandatory

This staff health form collects mandatory health information from new employees, including vaccination and serology records. Employees must submit this form within 4 weeks of starting, along with copies of relevant medical records. The form asks about history of diseases like hepatitis B, measles, mumps and rubella, as well as vaccinations for these and other diseases like pertussis and tuberculosis. Based on the responses, the employer will determine which vaccinations or immunizations are required. The employee must sign the form, and the employer will follow up on any missing information or required screening.

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52 views1 page

Staff Health Form: - All Fields Are Mandatory

This staff health form collects mandatory health information from new employees, including vaccination and serology records. Employees must submit this form within 4 weeks of starting, along with copies of relevant medical records. The form asks about history of diseases like hepatitis B, measles, mumps and rubella, as well as vaccinations for these and other diseases like pertussis and tuberculosis. Based on the responses, the employer will determine which vaccinations or immunizations are required. The employee must sign the form, and the employer will follow up on any missing information or required screening.

Uploaded by

Yhr Yh
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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STAFF HEALTH FORM

This form is to be completed by all staff before, OR within four weeks of commencement of employment & forwarded to Human Resources.

ALL FIELDS ARE MANDATORY

Employees Name: Home Address: Postcode: Phone Numbers: Commencement Date: Position: Home: / / Date of Birth: Ward / Department: Suburb: Staff ID Number: Mobile: / /

Have you worked or been cared for in a Health Care Facility outside of Western Australia in the last 12 months? Yes No If yes, where?: Date:

Please attach photocopies of ANY supporting evidence of relevant serology (blood tests) and/or vaccination records, WITHIN FOUR WEEKS of your commencement date, to assist in this assessment.
Disease Have you had the actual disease? Have you ever been vaccinated? Vaccination Course completed? Year? Have you had a blood test/serology? Year?

Have you ATTACHED previous Vaccination and Serology results?

Immunisation / Serology Required? (OFFICE USE ONLY)

Hepatitis B

Yes / No / Unsure

Yes / No / Unsure Year: Yes / No / Unsure Year: Yes / No / Unsure Year: Yes / No / Unsure Year:

Yes / No Year: Yes / No / Unsure Year: Yes / No / Unsure Year: Yes / No / Unsure Year:

Yes / No / Unsure Year: Yes / No / Unsure Year: Yes / No / Unsure Year: Yes / No / Unsure Year:

COPY OF RESULTS ATTACHED: Yes / No

Serology: Yes / No Immunisation: Yes / No Serology: Yes / No Immunisation: Yes / No

Measles Mumps Rubella

Yes / No / Unsure Yes / No / Unsure Yes / No / Unsure

COPY OF RESULTS ATTACHED: Yes / No

Serology: Yes / No Immunisation: Yes / No Serology - Yes / No Immunisation - Yes / No

Tuberculosis

Yes / No / Unsure Year:

Yes / No / Unsure Year:

N/A

N/A

N/A

Quantiferon Gold Testing Recommended: Yes / No

Pertussis (Whooping Cough)

Yes / No / Unsure Year:

Yes / No / Unsure Year:

N/A

N/A

COPY OF RESULTS ATTACHED: Yes / No COPY OF RESULTS ATTACHED: Yes / No

Immunisation Recommended: Yes / No

Chicken Pox

Yes / No / Unsure Year:

Yes / No / Unsure Year:

N/A

Yes / No / Unsure Year:

Serology: Yes / No Immunisation: Yes / No

Employees Signature:

Office Use Only:


MRSA Screening required?: Date Serology Form sent: Referral to IDP & Info letter sent: Date 1 Follow Up Letter sent: Date Assessment Finalised: Date Non-Compliance Recorded:
Updated: December 2011
st

Yes No

Date Screening Form sent: Date Recommended Vaccination Letter sent: Reason: ________________ Date: Date 2 Follow Up Letter sent:
nd

___/___/___ ___/___/___ ___/___/___ ___/___/___

___/___/___ Yes No

___/___/___ ___/___/___ ___/___/___

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