Centrum Care Homes Annual Health Declaration Form

  • Yearly Health Declaration Form

    If the answer is yes to any of the questions in this section, please give full details in the space provided of the dates, duration and outcome of any health areas disclosed. The more information you can provide us will ensure that we can support you appropriately during your employment. When this document is completed a member of staff will meet with you to complete the Managers Assessment Form where you will be able to discuss the information provided. Centrum Care Homes has a duty of care to ensure that you are fit to work therefore a further medical report may be requested. If you are considered to have a disability, Centrum Care Homes also has a legal responsibility to make “reasonable adjustments” where practicable to ensure that you are treated fairly. Please note: you must inform your local office immediately if your health changes so that we can offer the correct support.

  • Do you have or have ever had:

  • Anything that affects your physical ability to walk, balance, bend etc…?*
  • Anything that affects your hearing (even after correction with a hearing device)?*
  • Anything that affects your eyesight in any way (even after lens correction)?*
  • Anything that causes severe pain?*
  • Anything that may affect your mental wellbeing (Anxiety, Depression, difficulties in dealing with Stress)?*
  • Any alcohol or drug dependency/misuse?*
  • Tuberculosis, Asthma, Bronchitis or any condition that may affect your breathing or chest?*
  • Anything that may affect your heart or blood pressure?*
  • Epilepsy or anything that may cause blackouts, seizures or fainting?*
  • Typhoid, Paratyphoid or Dysentery?*
  • Diabetes (Type 1 or Type 2)?*
  • Digestive or bowel disorder?*
  • Anything pertaining to your Thyroid?*
  • Anything relating to the Bladder or Kidney?*
  • Dermatitis or other skin problems?*
  • Varicose veins?*
  • Anything that has not been covered by the questions above?*

  • Other

  • Are you currently receiving medical treatment for a short term or long term health concerns?*
  • Have you any reason to believe you may be infected by any communicable disease?*
  • Do you have any allergies and if so are any of these life threatening?*
  • Have you ever left or been denied employment in an organisation on the grounds of ill health or been medically retired on the grounds of ill health?*
  • Will you need any special aids or adjustments or assistance to enable you to undertake the tasks set out in the job description of the post offered?*
  • Is there anything else that affects your health that you wish to disclose to us?*

  • Vaccinations

    Have you received vaccination for any of the following:
  • COVID*
  • If yes, please provide date of vaccination (first dose)
     - -
  • If yes, please provide date of vaccination (second dose)
     - -
  • If yes, please provide date of most recent booster
     - -
  • Tuberculosis BCG*
  • If yes, please provide date of vaccination
     - -
  • Rubella (German Measles)*
  • If yes, please provide date of vaccination
     - -
  • Tetanus*
  • If yes, please provide date of vaccination
     - -
  • Flu*
  • If yes, please provide date of vaccination
     - -
  • Hepatitis B (with certificate of vaccination)*
  • If yes, please provide date of vaccination
     - -

  • It may be a requirement of any assignment that you have a Hepatitis B vaccination.  Restrictions may apply if you do not have a current certificate of vaccination.

  • Night Workers only

    Please complete this section only if a you are night worker or work nights ad hoc
  • Under the Working Time Regulations 1998 if you are classed as a night worker.  You are entitled, if you wish, to a free health assessment to ensure that you are suited to working at night. If you wish to have a free health assessment, please indicate below

  • Declaration

  • I certify that I am fit for work in the care industry and understand I must inform my office if anything changes with regards to my health and/or ability to work

  • Date*
     - -
  • Should be Empty: