Agreements Lydian Care Healthcare Agreements Step 1 of 2 50% Full Name First Last 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(Required) DD slash MM slash YYYY Signature(Required)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. RECEIPT OF INFORMATION DECLARATION I can confirm that I have received; read & understood: Health Care Worker Job Description Lydian Care Staff Handbook NISCC Code of Practice A copy of the above documents is available via our staff resources area of our website and your Lydian Care Learning Portal. SAFEGUARDING DECLARATION I confirm that on leaving Lydian Care I will return all uniforms, name badges and any Lydian confidential information I have been provided as part of my employment. CONFIDENTIALITY DECLARATION Registration implies acceptance of our code of confidentiality. You should safeguard the privacy of clients and not disclose ANY information about them to anyone other than those involved in their care, without agreement of the client or someone authorised to act on their behalf. If you are worried by any information you have obtained and consider that you should disclose it to someone else, please contact Lydian Care. Failure to observe confidentiality will be regarded as Gross Misconduct, which could result in your membership being terminated. WORKER DECLARATION The information that I have given in this registration form is, to the best of my knowledge, complete and accurate in all aspects. I understand that giving false information will knowingly disqualify me from membership with Lydian Care. I also understand that the RQIA have the right to access my personal record. In signing and dating below I agree to the RECEIPT OF INFORMATION DECLARATION, SAFEGUARDING DECLARATION, CONFIDENTIALITY DECLARATION & WORKER DECLARATION AS DETAILED ABOVE. Date(Required) DD slash MM slash YYYY Signature(Required)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.
