Name
Social security number
Address
Postal code and postal city
Email (Employees)
Telephone (employee)
Professional role
Workplace
Do you feel healthy?
Have you had a prolonged fever, prolonged cough or involuntarily lost weight in the last 6 months?
If yes – have you sought care for this?
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?
Are you vaccinated against measles?
Have you had Rubella?
Are you vaccinated against rubella?
If you have been vaccinated against measles and rubella (included in the same vaccine): How many doses of vaccine have you received?
Have you had chickenpox?
Are you vaccinated against chickenpox
If you have been vaccinated against chickenpox: How many doses of vaccine have you received?
Do you have ongoing skin disease, wounds, eczema or skin infection?
If yes, where on the body are the problems?
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?
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?
Are you vaccinated against Hepatitis B?
If yes, please indicate how many doses of hepatitis B vaccine you have received?
Have you been treated for tuberculosis?
Have you previously been tested for tuberculosis with an immune test (skin test tuberculin test/PPD or blood test IGRA-test/Quantiferon TB)?
Have you lived with someone with tuberculosis or a long-term cough without another diagnosis?
Which country were you born and raised in?
In which countries outside Western Europe, North America, Australia or New Zealand have you lived in for more than 3 months?
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?
If you have been vaccinated against diphtheria, when was the last time you received a booster dose?
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.
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