Healthcare Agreements

Step 1 of 2

  • TO BE COMPLETED BY THE HEALTH CARE WORKER

     I confirm that I understand my obligations as a health care worker, and I undertake to comply with any guidance issued by any regulatory or professional body relevant to my post.  I am aware that I must not allow my own health condition to endanger patients. I also confirm that I am not aware of having any medical disorder which would in any way restrict my clinical practice (including exposure prone procedures) or place patients at risk.

    If I have travelled to a high risk country for a period of 4 weeks or more in the last 5 years I can confirm that I have had appropriate TB follow up screening.

    I confirm I have not been the subject of any issues of concern or investigations of any form regarding my clinical performance.

     

  • Date Format: DD slash MM slash YYYY
  • Please either draw using the pen with your mouse or if you are completing on your mobile or handheld device use your finger or stylus to sign your name.
  • TO BE COMPLETED BY THE AGENCY

     I confirm that the Health Care Worker detailed above, has had the appropriate and in date occupational health screening procedures carried out, including those detailed in the Department of Health’s publication “Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New Health Care Workers”.  I also confirm that to our knowledge, there are no known medical restrictions on their practice and that they are fit to carry out their full range of duties which may include exposure prone procedures.

     

    I also confirm that if this practitioner has travelled to any high risk countries (as detailed on the World Health Organization Website) for a period of 4 weeks or more in the last 5 years that their TB status has been checked since that travel by our Occupational Health provider and that results have been cleared through a UK based laboratory.

     

    I confirm this practitioner is not to our knowledge the subject.to any issues of concern or investigations of any form regarding their clinical performance.

     

    Signed        

    Print Name DEAN FOSTER - HR MANAGER

     

    The above statements are only valid if signed within the 12 weeks immediately prior to the date of the assignment in the Trust.