Care Declaration


Please tick if you have completed the following training within the last 12 months. Please enclose copies of your training certificates


All applicants must complete the enclosed health questionnaire to enable us to establish your fitness for work. We would ask all OVERSEAS candidates to provide a medical statement from their GP or medical department confirming your state of health. Your details will be passed to our Occupational Health Doctors to establish your fitness for work. Please sign the declaration below to allow staffing network to release your information for inspection. I consent to staffing network releasing my health and immunisation records for review to staffing network qualified Occupational Health Advisor. I understand that based on this review I may be required to undergo a medical examination to establish my fitness for work. I confirm that I will immediately inform staffing network in confidence if I am HIV Positive, HepB positive or if I have AIDS in accordance with the Department of Health guidelines. I am aware of my obligations regarding MRSA contact and the need for screening. I agree to immediately inform staffing network should my general condition of health change. I confirm that I will immediately inform Staffing Network of any covid-19 situations occurred and I will also provide Staffing network my negative Covid-19 Test in order to be sent out to work.  I will inform staffing network  immediately if I discover that I am pregnant. I understand that withholding information or giving false answers may lead to dismissal. I also hereby consent to staffing network obtaining further information regarding my health from my GP or Occupational Health Department.


Each agency worker has a responsibility at the start of their first shift to become familiar with the Client’s general policies including, without limitation, those relating to Crash Call Procedures, the Hot Spot Mechanism for alerting security staff that an individual is in trouble, Fire Policy and the Violent Episode Policy.
Please read before signing
I declare that by signing this form I am stating that I am legally entitled or allowed to work in the United Kingdom, with or without necessary permission from the Home Office or any other relevant authority. If I have secured permission to work, I have included copies of all documentation. I also acknowledge that if it is found that I am working without the relevant permission, my employment will be terminated with immediate effect and all details passed to the relevant authorities. I agree that Staffing Network retains the right to hold this registration form and any other data required to process it and pass onto any authorised third party and the details held within. I also agree to use all reasonable efforts to assist to comply with the Data Protection Act 1998. In addition, I confirm that that all the information provided is true and accurate and that I have received and agree to Staffing Network terms of engagement and Staff Handbook.


The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. Our aim is to promote and maintain the health of all people at work. Before health clearance is given for employment you may be contacted by the Stafiing Network and may need to be seen by an occupational health advisor or physician.



All staff groups complete this section
If your answer is yes, please provide further details of the condition, treatment and dates.


Please indicate which off the following Immunisations you have been vaccinated against and include your vaccination reports when returning your registration.
All applications who cannot provide a registered DBS or full immunisation record will be required to complete at their own cost. Staffing Network Providers will cover the cost of any Mandatory Training updates however cancellations outside of 48 hours and late attendances will be charged to the candidate. Candidates will be required to purchase uniform if required at the cost of £20 this will be deducted from your timesheet once you have started working through us.


Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006)


Do you have any of the following? Please select if applicable:

ADDITIONAL INFORMATION (If you have answered yes to any questions above please provide additional information below)


Have you had any of the following immunisations?*


(Please send the following)


You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity.


We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare).

Rubella, Measles and Mumps

Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella Measles and Mumps.

Hepatitis B

You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above.