HM 144: Periodic questionnaire to assess immunity for individuals who may be susceptible to infection in the course of their work at The University of Sheffield This form is confidential to Health Management Ltd. Section 1 should be completed by the Manager responsible for the employee and then passed to the employee for completion. The employee should then scan and email it to TeamA4@healthmanltd.com Section 1 – Referrers Details Surname Forename(s) Faculty or Professional Services What potentially infectious material is the employee working with? 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 HM144 190416 Confidential Employee Name: DOB: Page 1 of 2 Section 3 – Pre-existing risk conditions Yes Have you ever suffered from any of the following? Eczema or chronic skin condition? Asthma? Disorders or diseases affecting the immune system? Chronic illness affecting the lungs, bowels, heart, liver, kidney or nervous system? Treatment with steroids, immunosuppressive drugs, anti-tumour necrosis factor agents or long term antibiotics (e.g. penicillins or oxytetracycline) No Are you currently pregnant or breastfeeding? If yes, please give details below or add any other comments In cases of recurrent infections, treatment with antibiotics, steroids or other drugs or other illness that may affect your immune competence you should inform your Line Manager. 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 TeamA4@healthmanltd.com Please note ‘fit’ certificates will be sent to occupationalhealth@sheffield.ac.uk for onward circulation to the relevant Manager / Employee. HM144 190416 Confidential Employee Name: DOB: Page 2 of 2