Occupational Health Service
The Education Centre
St Thomas’ Hospital
Westminster Bridge Road
London SE1 7EH
Incoming Overseas Electives Students Immunity Screening
Dear Incoming Overseas Electives Student,
In order to expedite your immunity clearance please read the following information carefully before completing the attached form.
The Occupational Health Service (OHS) at Guys & St Thomas’ NHS Foundation Trust (GSTT) provides occupational health provision for King’s College London undergraduate healthcare student. To obtain occupational health immunity screening clearance for your electives placement, you must comply with GSTT immunity requirements by providing evidence of immunity to certain work-related, vaccine preventable communicable diseases.
GSTT OHS does not provide blood test or vaccination appointments for overseas electives students. If you do not hold the required immunity evidence, please obtain this from your doctor, private clinic or current Occupational Health provider before arrival in the UK.
Mandatory Screening / RecommendedMeasles & Rubella / Evidence of:
· Blood test (Measles Antibody and Rubella Antibody) OR
· Having received 2 doses of the combined Measles, Mumps and Rubella (MMR) vaccine
Varicella (chicken pox) / Evidence of:
· History of the disease OR
· Blood test (Varicella Antibody) OR
· Having received 2 doses of the varicella vaccine
Please note: individuals from tropical and subtropical climates, need to provide Varicella Antibody regardless of the history
Tuberculosis (TB) / · Free from symptoms
· Individuals from a high incidence area (incidence rate of 40 per 100,000 or greater are considered to have high incidence of TB according to WHO, http://www.who.int/tb/country/data/profiles/en/), copy of chest x-ray (CXR) report is required / BCG
Hepatitis B / 3 doses of Hepatitis B immunisation
Evidence of immunity (HBsAb >100)
Acceptable documentary evidence of immunity to communicable diseases includes GP report(s), laboratory result(s) or occupational health report(s). All documentary evidence must be in English and be clearly signed with the name and designation of the practitioner issuing the report.
Seasonal Influenza
All overseas electives students are encouraged to participate in the annual influenza vaccination programme at their placement trust.
Exposure Prone Procedure (EPP)
You must NOT carry out EPP at your elective placement(s).
Exposure Prone Procedures are those invasive procedures where there is a risk that injury to the worker may result in exposure of the patient’s open tissues to the blood of the worker. These include procedures where the worker’s gloved hands may be in contact with sharp instruments needle tips or sharp tissues (e.g. spicules of bone or teeth) inside a patient’s open body cavity wound or confined anatomical space where the hands or fingertips may not be completely visible at all times.ALL incoming elective students must complete the Incoming Overseas Electives Students Immunity Screening Questionnaire.
Where the evidence of immunity cannot be provided and the electives placement is for less than 21 consecutive days, in addition to Immunity Screening Questionnaire, you will be required to complete the Incoming Overseas Electives Students Communicable Diseases Questionnaire by the placement manager/supervisor on the 1st day of placement.
This form must be completed at least 4 weeks prior to proposed date of placement. Failure to do so may result in delay in the provision of immunity clearance and subsequent placement date.
Please email your completed form to KCL elective office:
Dental electives:
Medical electives:
Other electives: please check with your elective organizer
Yours sincerely,
The Occupational Health Service
Occupational Health Service
The Education Centre
St Thomas’ Hospital
Westminster Bridge Road
London SE1 7EH
Incoming Overseas Electives Students Immunity Screening Questionnaire
To be completed by ALL prospective overseas electives students whose role involves access to/contact with patients and/or specimens.
Surname: / First Name:Date of Birth: / Male / Female
Email Address: / Telephone number:
Home Address: / Country of residence:
Medical electives placement
Dental electives placement
Others please specify ______/ Area of intended placement/hospital:
Date(s)of placement(s): / Length of placement(s) less than 21 days?
Yes No
Proposed duties to be undertaken during placement(s):
Immunisation Details
Have you received 2 doses of combined MMR vaccine?
· YES
Please provide documentary evidence of immunisation
· NO
Please provide laboratory result indicating immunity
Varicella (chickenpox)
Have you had past Varicella infection?
· YES
If you are from a tropical or subtropical climate (sub-Saharan Africa, Southeast Asia, Caribbean and central America) please provide laboratory result indicating immunity regardless of the history
· NO
Please provide laboratory evidence of your immunity OR documentary evidence of having 2 doses of Varicella vaccine
Tuberculosis (TB)
Have you experienced any of the following symptoms in the past 3 months?
· Unexplained cough lasting more than 3 weeks Yes No
· Coughing up blood Yes No
· Unexplained weight loss Yes No
· Fever and night sweats Yes No
If you are from TB high risk country (see covering letter for definition), you must provide chest x-ray report
Hepatitis B
Have you been immunised against hepatitis B?
· YES
Please provide the dates of immunisation and laboratory result (hepatitis B surface antibody)
· NO
KCL promotes safe practice to ensure that the risk of exposure to infectious diseases is reduced as far as possible. However, candidates who do not have evidence of immunity against TB (e.g. previous BCG vaccine or positive Tuberculin Skin Test) and those who are not immune to hepatitis B and accept the offer of a placement, accept full responsibility should they contract TB or Hepatitis B during their placement at GSTT.
Applicant’s Signature: Date:Occupational Health Service
The Education Centre
St Thomas’ Hospital
Westminster Bridge Road
London SE1 7EH
Incoming Overseas Electives Students Communicable Diseases Questionnaire
ONLY complete this form if evidence of immunity cannot be provided AND the elective placement is for less than 21 consecutive days
This questionnaire must be completed by the elective student with the placement manager/supervisor on the first day of placement and will be kept in the elective student’s personnel file held locally.
If the elective student has answered ‘Yes’ to any of the questions below, they should not be permitted to commence the placement and should be asked to contact occupational health for advice as soon as possible.
Surname: / Forename:Date of Birth: / Male / Female
Contact Address: / Contact telephone no:
Contact e-mail:
Name of placement manager/supervisor: / Date(s) of placement:
Area of intended placement: / Length of placement:
Have you been exposed to any of the following communicable diseases in the past 21 days? / Yes / No
Measles
Rubella (German Measles)
Varicella (Chickenpox)
Tuberculosis (TB)
Have you had any of the following in the past 3 months? / Yes / No
Cough which lasted more than 3 weeks
Unexplained weight loss
Intermittent fever with night sweats
Investigation(s) for tuberculosis
Contact with a family member/friend with whom you share a home, diagnosed with
TB
Please answer the following: / Yes / No
Do you have a skin rash?
In the past 48 hours have you experienced diarrhoea and/or vomiting?
Elective student’s signature: / Date:
Placement supervisor/manager signature: / Date:
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Incoming Overseas Electives Students Immunity Screening 2014