Health declaration for new employment

Job seekers

Name

Social security number

Email (Employees)

Telephone (employee)

Workplace

General health

Do you feel healthy? Ja Nej

Have you had a prolonged fever, prolonged cough or involuntarily lost weight in the last 6 months? Ja Nej

If yes – have you sought care for this? Ja Nej

Measles/Rubella/Chickenpox

If you were born in Sweden after 1980 and received all vaccinations at the Child Health Centre (BVC) and at school, you are vaccinated against measles and rubella with two doses. In Sweden, you may have been vaccinated against chickenpox privately, but the most common is instead that you have had the disease. Different countries' vaccination programs differ, so if you were born and/or raised outside Sweden, you may have received both more and fewer vaccinations.

If you are unsure about which vaccines you have received, regardless of where you grew up, if possible, contact a family member who may know if you have received these vaccines (or have had the disease) before you tick the box do not know.

Measles/Rubella/Chickenpox

If you were born in Sweden after 1980 and received all vaccinations at the Child Health Centre (BVC) and at school, you are vaccinated against measles and rubella with two doses. In Sweden, you may have been vaccinated against chickenpox privately, but the most common is instead that you have had the disease. Different countries' vaccination programs differ, so if you were born and/or raised outside Sweden, you may have received both more and fewer vaccinations.

If you are unsure about which vaccines you have received, regardless of where you grew up, if possible, contact a family member who may know if you have received these vaccines (or have had the disease) before you tick the box do not know.

Have you had measles? Ja Nej Vet ej

Are you vaccinated against measles? Ja Nej Vet ej

Have you had Rubella? Ja Nej Vet ej

Are you vaccinated against rubella? Ja Nej Vet ej

If you have been vaccinated against measles and rubella (included in the same vaccine): How many doses of vaccine have you received? 1 dos 2 eller fler doser Vet ej

Have you had chickenpox? Ja Nej Vet ej

Are you vaccinated against chickenpox Ja Nej Vet ej

If you have been vaccinated against chickenpox: How many doses of vaccine have you received? 1 dos 2 eller fler doser Vet ej

Skin/MRSA

Do you have ongoing skin disease, wounds, eczema or skin infection? Ja Nej

Have you worked in healthcare (including exchange/internship) or been treated as a patient in a hospital in a country outside the Nordic region during the last 6 months? Ja Nej

Hepatitis

Hepatitis B can be vaccinated against as an individual disease or with a combination vaccine against both hepatitis A and B.

Hepatitis

Hepatitis B can be vaccinated against as an individual disease or with a combination vaccine against both hepatitis A and B.

Do you have or have you had hepatitis B or hepatitis C? Ja Nej Vet ej

Are you vaccinated against Hepatitis B? Ja Nej Vet ej

If yes, please indicate how many doses of hepatitis B vaccine you have received? 1 dos 2 doser 3 eller fler doser Vet ej

Latent tuberculosis

Have you been treated for tuberculosis? Ja Nej Vet ej

Have you previously been tested for tuberculosis with an immune test (skin test tuberculin test/PPD or blood test IGRA-test/Quantiferon TB)? Ja Nej Vet ej

Have you lived with someone with tuberculosis or a long-term cough without another diagnosis? Ja Nej Vet ej

Which country were you born and raised in?

Diphtheria

If you were born and raised in Sweden and have received all childhood vaccinations at the Child Health Centre (BVC) and at school, you have been vaccinated against diphtheria. If you grew up in another country, you may have been vaccinated, but the programs differ from country to country.

If you are unsure about which vaccines you have received, regardless of where you grew up, if possible, contact a family member who may know if you have received these vaccines before you tick the box do not know.

There is no vaccination program for booster doses of diphtheria, but you may have taken booster doses yourself at a vaccination office or, for example, in connection with military service, wound injury or employment. The booster doses for tetanus usually also include diphtheria, so please state in the comment whether you have received the tetanus vaccine in the last 20 years.

Diphtheria

If you were born and raised in Sweden and have received all childhood vaccinations at the Child Health Centre (BVC) and at school, you have been vaccinated against diphtheria. If you grew up in another country, you may have been vaccinated, but the programs differ from country to country.

If you are unsure about which vaccines you have received, regardless of where you grew up, if possible, contact a family member who may know if you have received these vaccines before you tick the box do not know.

There is no vaccination program for booster doses of diphtheria, but you may have taken booster doses yourself at a vaccination office or, for example, in connection with military service, wound injury or employment. The booster doses for tetanus usually also include diphtheria, so please state in the comment whether you have received the tetanus vaccine in the last 20 years.

Are you vaccinated against diphtheria? Ja Nej Vet ej

If you have been vaccinated against diphtheria, when was the last time you received a booster dose? <20 år sedan >20 år sedan Vet ej

Approve and submit

By submitting the health declaration, you ensure that the information is correct.

At the same time, you agree that your health declaration is sent to the occupational health service for assessment and that the ordering manager receives overall feedback based on your completed health declaration.

You can save a copy of the health declaration as a pdf after you have submitted the form.

Approve and submit

By submitting the health declaration, you ensure that the information is correct.

At the same time, you agree that your health declaration is sent to the occupational health service for assessment and that the ordering manager receives overall feedback based on your completed health declaration.

You can save a copy of the health declaration as a pdf after you have submitted the form.