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Personal Information
At your interview, were the demands of the job and hazards that you may be exposed to at work discussed with you? For example: manual handling, exposure to blood body fluid, and emergency and distressing situations?
Do you currently have any personal health issues that may require some changes to the duties you need to perform?
Do you have or have you had any illness, operation or disability that has been managed by a Health Professional? For example diabetes, epilepsy, depression
Are you currently taking any medication(s) that may affect your ability to work? For example heart medication, epilepsy medication, insulin, anti-depressants
Are you aware of any workplace factors that may impact on your health? For example cleaning products, hand washing products
Do you currently have an open ACC/injury claim?
Do you have any allergies or sensitivities?
What is you allergy to? Please tick one of the below options
Do you have any vision difficulties aside from wearing lenses/glasses?
Do you require any modifications in the workplace as a result of your vision problem?
Do you have any hearing difficulties?
Do you require any modifications in the workplace as a result of hearing changes?
Do you have a skin condition such as dermatitis, eczema, recurrent boils and/or psoriasis?
Do you have any symptoms now?

The position you have applied for may require you to perform tasks involving the following: Moving patients or heavy objects Prolonged standing or sitting Pushing, pulling, reaching Bending Calming and Restraint Repetition of any of the above

Do you have any physical condition(s) which may prevent you from accomplishing the tasks in your role safely and without harm to yourself or others?
In the past 2 years have you had any back, neck, shoulder, arm or leg problems?
Have you ever had any health problems related to repetitive work or use of a computer?
Have you required time off work or been placed on restricted duties as a result of a joint or muscle condition? E.g. between 1-7 days, 7-28 days, 1-3 months, more than 3 months
Will your role involve contact with patients?
Will your role involve handling of clinical specimens?
Will your role require you to go into clinical areas (e.g. wards)?

NB: Cleaners, orderlies, ward clerks and security will either have face to face contact or handle waste material

Previous education institute attended and District Health Board(DHB) employment (if applicable)

Biological Screening

This Section is for candidates who will have contact with patient and/or infectious material.

If you have proof of immunity (vaccination records) and/or test results for the following please submit them with your application by attaching them in the next section:

  • -Hepatitis B
  • -Varicella (Chicken Pox)
  • -Measles
  • -Mumps
  • -Rubella
  • -TB Blood test (Quantiferon TB Gold) or 2 Step Mantoux tests or Heaf tests)
  • -Chest X-Ray report (If you have had a positive Mantoux/Heaf/TB blood test previously)
  • -MRSA results less than 2 months old

Copies of any of the above can also be scanned and emailed to

Alternatively you can mail your results to Occupational Health and Safety Services, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland, New Zealand 

Please note that any testing that will be required may delay the clearance process

Infection Prevention

Do you have a chronic respiratory condition such as Bronchiectasis, Cystic Fibrosis?
Do you have Chronic Sinusitis - a condition that lasts at least 12 weeks despite being treated and causes at least TWO of the following symptoms: nasal congestion, mucus discharge from the nose or that drips down the back of the throat, facial pain, press

Blood Body Fluid Exposure

This section is to ensure that you are receiving correct post-exposure follow up.

Have you had a work-related blood/body fluid exposure within the past 6 months that has required follow up? E.g. needle stick injury; splash; scalpel injury
Do you give consent for Occupational Health and Safety Service to obtain a copy of baseline and follow up test results from your previous employer?


Have you ever been diagnosed with Hepatitis B Infection?
Have you been vaccinated for this disease?
Hepatitis B is a 3 dose vaccination. Did you complete the full course?

Varicella (Chickenpox)

Have you ever been diagnosed with Chickenpox?
Have you been vaccinated against Varicella/Chickenpox?
Varicella is a 2 dose vaccination. Did you complete the full course?


Have you been vaccinated for Measles with a vaccine containing Measles such as MMR (Measles/Mumps/Rubella)?
MMR is a 2 dose vaccination. Did you complete the full course?


Have you been vaccinated for Rubella?


Have you ever been vaccinated for Mumps with a vaccine containing Mumps such as MMR?
MMR is a 2 dose vaccination. Did you complete the full course?


Have you been vaccinated for Pertussis?


Have you been vaccinated for Tetanus?

Lab Results

Please attach all lab results/vaccination records that you have for any of the diseases above using the button below. HINT: Hold down control to select multiple files. The files must be in the same directory.

FREE vaccination is available for candidates as required

You indicated you will not have contact with patients or clinical specimens

Please skip to the next page

Were you born in New Zealand?
Have you worked in any of the following work settings:
Do you have a chronic illness such as kidney disease, diabetes, HIV or any immunosuppressive illness?
Do you take any immunosuppressive medication, including long-term oral steriods?
Have you had a Chest XRay within the last 12 months?
Have you ever been exposed to anyone with Tuberculosis?
Have you ever been treated for Tuberculosis?
Have you ever had a test for TB? (i.e. Quantiferon TB Gold, 2 Step Mantoux or Heaf)
Did you have positive results?
Did you have a Chest XRay?
Have you been involved in a contact trace for a positive TB case since your last negative Quantiferon test/Mantoux?

Tuberculosis Symptom

Do you have as much energy as you think you should have for your age? Please select between 0-5
Do you have a persistent cough lasting > 3 weeks or a cough most days?
Does your cough produce a lot of phlegm?
Have you ever coughed up blood?
Do you wake at night sweating so much you have to change your bed clothes?
Have you lost any weight over the last 6 months without meaning to?
Have you had urinary tract infections without your doctor being able to find a cause?
Have you had any lumps in your neck, armpit or groin which won't go away?

Counties Manukau Health has a Smoke Free Policy which prohibits staff and visitors from smoking anywhere in its facilities or grounds. If you smoke and wish to receive assistance, a Smoking Cessation Programme is available to all staff at Counties Manuka

Do you smoke?

Other Supporting Files

Please select one of the options:

Please be aware that for security reasons we only allow this file types to be uploaded: doc/x, xls/x, pdf, jpg, png, bmp, gif

Privacy and Declaration Statement

I declare that to the best of my knowledge the answers in this application are correct. I understand that if any false or deliberately misleading information is given, or any material fact suppressed, I may not be appointed, or if I am employed, my employment may be terminated.

I authorise permission for Counties Manukau Health Occupational Health and Safety Service to gain access to my personal immunity status and immunisation information held at my Educational Institute, other DHB Occupational Health and Safety Service, General Practitioner and CMH Medical Information Portal (CONCERTO).

I understand that the information related to health screening required by Occupational Health and Safety Service will be placed on my personal file. I also have a right to access this information and to obtain copies of my test results.

I consent to CMH Occupational Health and Safety Service disclosing this information to other DHB Occupational Health and Safety Services in relation to their Pre-Employment Health Screening, Contact Tracing or Health Monitoring requirements and my nominated General Practitioner subject to the Privacy Act 1993. The requirements of the Privacy Act 1993 will be applied to the sharing of any information provided through the pre-employment health screening process to other parties either within the organisation or externally.

I understand and accept that I may be required to attend a health assessment with Counties Manukau Health Occupational Health and Safety health practitioners.

I consent to information on my personal immunity status and immunisation to be made available to my manager for the purposes of assisting with managing staff and patient safety, and for emergency planning and response purposes.

I consent to information being made available to my hiring manager regarding work place accommodation requirements, based on my pre- employment health screening information.

A disciplinary process and/or investigation relating to the provision of information during the pre-employment medical assessment(s) and/or questionnaires: and/or Medical examination and/or medical disengagement process

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