Health Surveillance Consent

Health Surveillance Consent form

Step 1 of 9

11%

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Company(Required)

Job Title(Required)

I understand that all personal data (including special category health data) information will be collected for the purposes of providing occupational health advice to my employer. This data is entirely confidential to Innovate Healthcare and will not be revealed to anyone else, either inside or outside the Company unless with my consent, if there is a legal obligation, or it is in the public interest.(Required)

Yes

I understand my employer has a legal obligation to carry out health surveillance as a result of my being exposed to identified hazards at work, and that I have a legal and contractual obligation to comply with arrangements that my employer has made in respect of health surveillance.(Required)

Yes

In view of the above, I understand that specific refusal on my part to allow feedback to my employer on the results of health surveillance may result in decisions being made regarding my employment without the benefit of objective evidence and thus may be to my disadvantage.

Yes

I understand that I will be provided with a copy of the fitness statement if I request one.(Required)

Yes

I understand that any clinical information gained in this questionnaire will be retained securely on the Innovate Healthcare Information System only and deleted 40 years after the last entry is made in the records, or once I have left the company. I have the right to request a copy of the clinical records at any time by contacting Innovate Healthcare.(Required)

Yes

I hereby declare that the medical information that I have shared is true and accurate to the best of my belief and knowledge and have been recorded correctly and I have not knowingly withheld any medical information. I will notify Occupational Health if there are any changes to my health.(Required)

Yes

I consent following my assessment my results being escalated to an Occupational Health Nurse/ Occupational Health Physician for checking and if required an updated fitness certificate being generated and being reissued to my employer. This may mean that I require an onward referral to undergo a further health assessment by an Occupational Nurse or Doctor for employment purposes if necessary(Required)

Yes

Signature(Required)