HM 143:Tuberculosis Questionnaire for The University of Sheffield

Section 1 – Referrers Details

Surname
Forename(s)
Faculty or Professional Services
Reason for Submission:
  1. What is the employee working with?
  2. From your risk assessment, why do you feel there is a risk of TB exposure?

Employee to complete the following sections

Section 2 – Employee Details

Surname
Forename(s)
Date of Birth
Faculty or Professional Services
Department
Current Job Role
Previous Job Role
Contact Number
Home Address & Postcode
Employee email address
Have you completed this form before? / Select Yes or No tick box: Yes: What Date? MM/YY
If No, Please complete each section of this form in full
If Yes, complete sections 3, 4,5 & 6and sign and date form, before sending to Health Management.

Section 3 – Work History

Job Title
Date appointed to post
Previous employment, dates and positions held

Section 4 – Medical Details

Previous Tests

/ Yes / No / Not Sure
Have you ever been treated for TB?
Previous Heaf Test or Mantoux Test?
BCG scar present?
Have you worked abroad or travelled significantly?
If yes, please give details of countries and relevant dates

Section 5 – Current Medical details

Yes / No
Have you ever had any symptoms of a cough lasting more than 3 weeks?
Have you ever had any symptoms of night sweats?
Have you ever had any symptoms of unexplained weight loss and tiredness?
Do you suffer from any chronic lung or heart disorder?
Have you ever suffered from any bone marrow disorder or any form of cancer?
Have you had any treatment with steroids in the past 18 months?
Have you ever suffered from chronic kidney disease?
Do you have any other health problems that may affect your resistance to infection?
Have you ever had an operation?
Do you suffer from rheumatoid arthritis and/or receiving anti tumour necrosis factor therapy?
If yes, please give details below

Section 6 – Family History

Yes / No / Not Sure
Is there a family history of TB?
If yes, please give details of who and what contact you have with them (daily, weekly, monthly, never)
Yes / No / Not Sure
Is there any family history of immune-deficiency?
If yes, please give details below
Declaration
I declare that all foregoing statements are true to the best of my knowledge. I further declare that I have not omitted or falsified any material facts or details, which could have a bearing on my state of health. I am aware to notify my Manager/Supervisor should any symptoms develop.
I consent to the results of the assessment to be processed and the results provided to my employer to help safeguard my health, safety and welfare
In signing this form, I confirm my explicit consent within the meaning set out in the Data Protection Act (1998) for Health Management Limited to process my personal information.
Signed ______Date ______
Please scan and email it to

Please note ‘fit’ certificates will be sent to for onward circulation to the relevant Manager / Employee.

HM143 190416 Confidential Employee Name: DOB:Page 1 of 4