Are you in good health at the moment? Have you had a condition affecting your skin in the last two years? Are you currently receiving any treatment, medication, have any active implanted or body worn medical devices e.g. insulin pump, pacemaker or receiving specialist support? Do you require any workplace adjustments or support to enable you to undertake the post? Have you ever been diagnosed with Tuberculosis or Do you have symptoms which may be due to Tuberculosis e.g. an unexplained persistent productive cough, shortness of breath, fatigue, weight loss or night sweats? Have you been in contact with an individual with active open Tuberculosis or returned from a country where Tuberculosis incidence is > 40 per 100,000 per year? Please use the space below to provide further information on your answers: The Occupational Health Service may contact you via e-communications. Please tick if you DO NOT wish to receive e-communications from Occupational Health e.g. text appointment reminders, to annual patient satisfaction questionnaire Your details will not be shared with any third party
Are you in good health at the moment? Have you had a condition affecting your skin in the last two years? Are you currently receiving any treatment, medication, have any active implanted or body worn medical devices e.g. insulin pump, pacemaker or receiving specialist support? Do you require any workplace adjustments or support to enable you to undertake the post? Have you ever been diagnosed with Tuberculosis or Do you have symptoms which may be due to Tuberculosis e.g. an unexplained persistent productive cough, shortness of breath, fatigue, weight loss or night sweats? Have you been in contact with an individual with active open Tuberculosis or returned from a country where Tuberculosis incidence is > 40 per 100,000 per year? Please use the space below to provide further information on your answers: The Occupational Health Service may contact you via e-communications. Please tick if you DO NOT wish to receive e-communications from Occupational Health e.g. text appointment reminders, to annual patient satisfaction questionnaire Your details will not be shared with any third party
Application%20-%20elective%20placement%20for%20UK%20EU%20EAA%20medical%20students.docx