Bridge2Aid Volunteering Medical Questionnaire


    STRICTLY CONFIDENTIAL

    Section 1 of 3

    • Full Name (required)
    • Your Email (required)
    • Date of Birth (dd/mm/yyyy)

    In the event of you becoming ill or suffering an accident whilst on placement, the following information will be made available to the attending medical personnel. Please complete each section fully and accurately, and sign the declaration at the end. All information will be treated in the strictest confidence.


    Immunisation Record

    (must input dates or sign disclaimer field. One or other is compulsory.)

    Please provide an accurate record of all listed immunisations including the month and year.

    TYPE

    • Diphtheria (child series of three)

      Date (dd/mm/yyyy)

    • Polio (series of three)

      Date (dd/mm/yyyy)

    • MMR

      Date (dd/mm/yyyy)


    • If you do not know the dates of your childhood immunisations, please sign this disclaimer:

      All the child immunisations above are complete to the best of my knowledge.

      Applicant Signature

      Please tick this disclaimer:

      Date (dd/mm/yyyy)


    Adult Immunisation Record

    (compulsory – all must be answered)

    TYPE

    • Polio Booster (as adult)

      Date (dd/mm/yyyy)

    • Diphtheria (in last 10 years)

      Date (dd/mm/yyyy)

    • Tetanus (in last 10 years)

      Date (dd/mm/yyyy)

    • Typhoid

      Date (dd/mm/yyyy)

    • Yellow Fever

      Date (dd/mm/yyyy)

    • Rabies

      Date (dd/mm/yyyy)

    • Meningococcal Meningitis

      Date (dd/mm/yyyy)

    • Hep A (1st in series)

      Date (dd/mm/yyyy)

    • Hep A (2nd in series)

      Date (dd/mm/yyyy)

    • Hep B (1st in series)

      Date (dd/mm/yyyy)

    • Hep B (2nd in series)

      Date (dd/mm/yyyy)

    • Hep B (3rd in series)

      Date (dd/mm/yyyy)

    • Varicella (Chicken Pox)

      Date (dd/mm/yyyy)


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