Medical Assessment Form

MEDICAL FORM

Medical Self-Assessment

PLEASE COMPLETE ALL SECTIONS BELOW CLEARLY IN BLACK INK USING BLOCK CAPITALS

Job Title:

Surname

Other Names

Address:

Daytime Contact Number:

Alternative number

Date of Birth:

Email address:

Company ID Number:

Name of own Doctor:

Address of own Doctor:

Night Working

Do you have any health-related restrictions that prevent you from working night shifts?

Yes

2. TB Clearance

Have you in the last 5 years visited any high risk of TB infection countries? If necessary please reference the Department of Health Green Book for an updated list of countries.

Yes

Have you ever been diagnosed with TB?

Yes

Have you been in contact with anyone with TB in the last 6 months?

Yes

In the past 12 months, have you had a cough that has persisted for more than 3 weeks?

Yes

In the past 12 months, have you had any unexplained weight loss or fever?

Yes

Have you had a BCG vaccination in relation to Tuberculosis?

Yes

3. Therapeutic management of violence and aggression training (TMVA)

Alas Health Care attaches great importance to the health, safety and welfare of its staff and service users. It is for this reason that staff are trained in techniques to manage episode of violence, aggression, and challenging behaviour.

Staff who care for or who are in regular contact with service users may place themselves and others at risk if they are not appropriately trained. It is for this reason that as part of a member of staff’s terms and conditions of employment they can undergo this training.

TMVA incorporates a number of elements which have physical requirements, to include breakaway and physical intervention/restraint training.

Breakaway training is where staff are trained to breakaway/disengage from a potentially threatening or actual threatening behaviour by using a skill to separate or disengage in a safe manner. To be able to complete the physical element of this course all staff must be able to walk around the perimeter of a large training area, unaided and at a comfortable pace. All staff must have a good and pain free range of motion at all main joints of the body and must also be able to take hold and maintain a fully engaged grip with both hands. This training is for staff who do and do not work directly with patient care.

Physical Intervention/Restraint is a skilled hands-on method of physical restraint involving trained designated staff to prevent services users from harming themselves, endangering others or seriously compromising the therapeutic environment. Its purpose is to safely immobilise the individual concerned for the shortest possible time. To be able to complete the physical element of this course all staff must be able to walk around the perimeter of a large training area, unaided and at a comfortable pace. All staff must have a good and pain free range of motion at all main joints of the body and must also be able to take hold and maintain a fully engaged grip with both hands. Staff must be able to kneel on the floor on either leg and thereafter lie down on the floor and return to a standing position unaided. Staff may be required to perform the above movements on several occasions and on occasion for prolonged periods during the training. This training is for those staff engaged in direct patient care.

Do you have any back problems or any musko-skeletal problems which will cause difficulty with bending, lifting or standing for long periods of time?

Yes

Do you have any health restrictions or physical constraints that would prevent me from taking part in either Breakaway or Physical Intervention / Restraint training?

Yes

5. Work adjustments

Do you consider you require any adjustments to the tasks outlined in the job description because of any medical conditions you have indicated above?

Yes

If yes, what are these:

6. Employee Declaration & Consent

I declare that to the best of my knowledge, the information given in this form is a true and accurate. I am not aware of any health condition that would prevent me from carrying out my duties as set out in my job description, and I am aware that failure to disclose any relevant health condition may result in my employment being terminated.

I understand that I will be required to compete a full medical disclosure and that MaxLife Care will be notified of the outcome of this Work Health Assessment Screening which may include immunisation & MVA clearance.

Obtaining this information will involve the processing of special category data about you under the General Protection Act 2018. Accordingly, we are required to inform you of the reasons why we need to process this data and the lawful basis for doing so under the Data Protection Act 2018.

The legal basis for us obtaining this information is to manage your employment contract, to comply with our legal obligations for health and safety and/or, if necessary, to make reasonable adjustments.

If you answer yes to any of the above questions, we will need to await the feedback from our occupational health provider prior to you commencing work.

By signing this form, you consent to us processing this data.

Date

	Yes	No
Student Nurse
Qualified Nurse
Healthcare Assistant
None of the above

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Medical Self-Assessment

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