Health Declaration
Confidential
Newcross is an equal opportunities employer and these questions are asked solely for the purpose of ensuring that all employees/applicants can be considered on a fair basis.
We are committed to pursuing a policy to which we aim to ensure that all employees/applicants, with disabilities receive full and fair consideration at all times - this includes all types of job vacancies, training, career development and promotion opportunities.
Name
First Name Last Name
Branch
Date
Month Day Year
Date
How many days illness have you had in the past 2 years? Please give details including, approximate date reason for illness and number of days taken:
Do you currently have an illness or take any prescribed medication? YES/ NO if yes please give details
Have you previously been diagnosed with a serious illness that could reoccur? YES/ NO If yes please give details
Have you ever had or been treated for MRSA? YES/ NO
Do you have or have you ever had a bad back? YES/ NO If yes please give details
Have you had or are you waiting to have any major surgery? YES /NO If yes please give details
Have you ever been treated or are you currently receiving treatmentfor mental health problems? YES/ NO If yes please give details
Everyone who has direct contact with Patients or Service Users has a requirement to have the following vaccinations

Please state if you have had the following vaccinations along with the date:-
Tetanus
Polio
MMR
Rubella
Varicella (Chicken Pox)
Hepatitis 'B'
Newcross strongly advise that you have the above vaccinations and failure to do so is at your own risk.
Have you had Chicken Pox? YES NO
Have you had Shingles? YES NO
Do you consider yourself as having a disability? YES NO If yes please give details
Do you require any special considerations or reasonable adjustments tobe taken in respect of your disability, illness or diagnosis? YES NO If yes please give details
DECLARATION

By signing the below I can confirm that all of the information provided in this document is correct. I have disclosed, to the best of my knowledge, all relevant information in regards to the above. I agree to inform the Branch immediately if any circumstances in regard to my health change during the next twelve months.
Signature
Clear
Criminal Conviction Declaration
Confidential
Have you ever been cautioned or convicted of any offence? YES NO If yes please give details (NB. You must reply to this question as by virtue of the Rehabilitation of Offences Act 1974 (Exception) Order 1975 Schedule 1 Part 1 Clause 13 convictions which might, but for this provision be regarded as ‘spent’) –This must be disclosed
Is there any charge against you that remains to be dealt with by anycourt? YES NO If yes please give details
Other relevant facts:
DECLARATION

By signing the below I can confirm that all of the information provided in this document is correct and I also confirm that during the last twelve months, I am unaware of any incidents that have occurred that may give rise to, or have caused my inability to pass a DBS/PVG check.
Signature
Clear
Waking Night Protocol
Confidential
This protocol applies to all Newcross Healthcare staff working waking night shifts and is to be read and signed by staff to confirm their acceptance of the responsibilities prior to attending their first waking night shift.
Newcross clients, both Complex Care and Establishment, book staff to work waking nights to support vulnerable Service Users, often on a one to one basis.
It is essential that you, as a waking night worker, understand your responsibilities and are alert throughout the entirety of the shift.

Why it is important
Should a waking night worker fall asleep on shift, there are some very serious risks and possible consequences.
Firstly, there is the very worrying risk that a Service User could deteriorate or they could have an unobserved accident. Should a waking night worker fall asleep there is a concern that lack of care and observation could
result in injury and in more serious cases, death.
Newcross take all allegations of staff sleeping on duty seriously and claims of this nature will be subject to a full investigation which could result in dismissal for gross misconduct.

Duty to report
Due to the serious risks outlined above, there is also an additional expectation on all waking night workers to report any concerns they may have regarding other staff working with them who they observe/witness asleep on
duty. This applies to both Newcross staff as well as staff working for another provider/employer.
Should there be any questions or queries about this protocol, please contact your Business Centre Manager or for out of hours support contact the Central Services team.
If you feel you need to report an incident confidentially, please call the HR team.

DECLARATION

By signing the below I can confirm that I have fully read and understand the Waking Nights Protocol and confirm that I fully understand my responsibilities whilst working on waking night shifts.
Signature
Clear
Should be Empty:

Health Declaration

Criminal Conviction Declaration

Waking Night Protocol