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3. Health Declaration

You are here: Home / 3. Health Declaration

Health Declaration Form

For candidates to submit their health declaration form online.
  • Health Declaration - Confidential Please complete this form accurately and honestly.
  • DD slash MM slash YYYY
  • Please select your gender.
  • DD slash MM slash YYYY
  • Please select which role you have applied for.
  • Have you ever had, or do you currently have any problems with the following? You may have already entered some of this information above - If you answer yes to any of the below, please provide some brief information.
  • 14. Have you been vaccinated for any of the following:
  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • Drop files here or
    Max. file size: 80 MB.
      Please take a photo and upload your vaccine cards here.
    • It is your responsibility to inform your Manager immediately if any of the above changes.
    • I certify that the information I have provided is accurate and that I am in good health and fit to carry out the duties as described in the job description in relation to the role I am applying for.
    • Please either draw your signature in the box above or use your finger or stylus if on a touchscreen device.
    • TO BE COMPLETED BY GP
      Does the candidate have a BCG scar providing evidence of receiving their BCG vaccination.
      YES
      NO
      Has the candidate been administered the required vaccinations based on their submitted vaccination record to work on NHS/Hospital sites.
      YES
      NO
      In my professional opinion based on the information provided I declare the above-named candidate fit to work as a provider of health care in the capacity as a healthcare assistant.
      YES
      NO
      Doctor’s Signature:
       

       

       

       

       

      Doctor’s/ Clinic Stamp

       

      Print Name:
       
      Date:
       

       

       

       

       
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