Name: Khushal Khan Email: Doctor.khushalkhan@gmail.

com Date of Birth: 30/06/1984

Occupational Health Form

General Details

First Name: Khushal Surname: Khan

Mobile Number(s): 0923336668389 (Mobile) Email: Doctor.khushalkhan@gmai

l.com

Address Line 1: House No. 173, Street No. Address Line 2: Shahbaz town
06, Phase No. 01

Address Line 3: Address Line 4:

City: Quetta County: Other

Post Code: 87300 Country: Pakistan

Gender: Male Date of Birth: 30/06/1984

Clinical Site: Post:

Note: Should any of the pre-populated details on your OHF be incorrect, you will be able to change these details at a later point
by updating your NER Hire form.

Employment History

Employer Job Title Start Date End Date

Health Department Medicine Medical Officer 08/06/2011 03/04/2019

Government of
Balochistan, Pakistan.,
Health Department
Government of
Balochistan, Civil
Secretariat , Zarghoon
road Quetta , Pakistan.,
Phone Number:
0929201187

Sickness Absence History

I have not had any Sickness Absence in the last five years

Page 1 of 2
Name: Khushal Khan Email: Doctor.khushalkhan@gmail.com Date of Birth: 30/06/1984

Health and Ability Declaration

Category Question Is Applicable Additional Detail

TB In the last two years have No

you lived in or visited a
country other than Ireland
for more than one month?

TB In the last 2 years have No

you coughed up blood?

TB In the last 2 years have No

you suffered from
unexplained weight loss?

TB In the last 2 years have No

you suffered from
unexplained night sweats
or fever?

TB Do you have a BCG scar? Yes Got vaccinated as part of

routine vaccination in early
life.

TB Do you have a family No

member or close contact
who has been treated for
TB in the past 2 years?

TB In the last 2 years have No

you had unexplained
cough for more than three
weeks?

TB Have you ever been No

diagnosed with TB?

Page 2 of 2