Sample Pre Enrolement Health Questionnaire - Free Download | Page 3
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UCL Occupational Health Service
University College London Gower Street London WC1E 6BT
Tel: +44 (0) 20 7679 2802 Fax: +44 (0) 20 7209 0256
www.ucl.ac.uk/hr/occ_health
Accredited by the Faculty of Occupational Medicine
as a Safe, Effective, Quality OH Service
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To determine if you have had either past or current active infection with tuberculosis, you agree
that TB screening may be required. If the screening indicates previous or current infection, then a
prompt referral will be made for specialist advice and treatment. You agree that in these
circumstances your studies will be temporarily delayed. Your tutor will be informed of the
requirement to delay your studies but OH will not provide clinical information without your consent.
If you are disabled in any way, require special aids, or may have other special needs, please give
details of these in the details box on page 6.
In submitting this form you declare that the information you provide is true to the best of your
knowledge.
I declare that the information above is true to the best of my knowledge.
Signed:
PRINT Name:
Date:
Please print and take the completed form to your General Practitioner (GP) or equivalent and
request that they complete the questions below. You are responsible for any fee your GP may
charge. Scan the verified form as a complete document and return it as either a PDF or Word
document to uclstudentoh@ucl.ac.uk
You will be contacted regarding arrangements for required immunisations and tests by UCL OHS
following enrolment.
On the basis of this questionnaire and, where necessary, further occupational health assessment,
UCL OHS will advise on your medical fitness for the course, and any adjustments that your tutors
can consider to support you. Medical details will not be given to your tutors without your consent.
All information is kept in confidence by the OH Service and will not be used for any other purpose
other than that for which it is provided. If you require information on accessing your OH records
please speak to any member of the UCL Occupational Health team.
Candidates with specific health issues or disabilities are encouraged to enclose copies of
any relevant reports from their GP/family doctor/consultant/specialist with this health
questionnaire, if already available. This will speed up the process of assessing your
health information.
VACCINATIONS AND BLOOD TESTS
Ask your GP to give you any routine or childhood vaccinations that you have missed or are due. If
you have received vaccinations at school please advise your GP, as these records may not be
held at the surgery.
At UCL Medical School, contact with patients begins early in the programme. UCL medical
students are classed as EPP (exposure prone procedures) workers. For this reason, it is the
Medical School’s policy that students should be fully vaccinated and have had the blood tests
necessary for EPP clearance as early as possible. While it is not necessary to be EPP cleared in
order to complete the medical degree programme to the GMC’s satisfaction, there may be
restrictions on your clinical experience if you are not EPP cleared. EPP screening will be
undertaken for you by UCL OHS on enrolment.
You will need vaccination against hepatitis B. Since the course of three injections may take six
months to complete, we recommend that you start this as soon as possible.
source: ucl.ac.uk
