Application Form for Nurse on Call for Carer by gol87179

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More Info
									                                                                                                       REF NO:




                                                                 50 Patrick's Street, Cork, Ireland
                                                   Tel: (353) 21 422 2830 Fax: (353) 21 427 9939
                        Internet: http://www.nurseoncall.ie Email: nurseoncallcork@ireland.com




                                                                  50 Patrick's Street, Cork, Ireland
                                                    Tel: (353) 21 422 2830 Fax: (353) 21 427 9939
                         Internet: http://www.nurseoncall.ie Email: nurseoncallcork@ireland.com



                           APPLICATION FORM
                        APPLICATION FORM
Registered Nurse                                  Nurse On Call

HCA’s / Carers                                   Carers and Nurses Aides On Call

Other                                           _________________________

              Interview took
              Interviewed place in:
Interviewed took place in: took place in:

               Dublin                    Dublin

               Cork                      Cork

               Drogheda                  Drogheda

                            Elsewhere ________________
               Elsewhere ________________

Have you ever registered / worked with Nurse On Call / Carers and Nurses
Aides On Call before?

                        Yes                            No
Form No: 184      Revision Status: 1




                                                              1
                                                                                                         REF NO:




                                                                        50 Patrick's Street, Cork, Ireland
                                                          Tel: (353) 21 422 2830 Fax: (353) 21 427 9939
                               Internet: http://www.nurseoncall.ie Email: nurseoncallcork@ireland.com




  APPLICANT DETAILS                        (BLOCK CAPITAL LETTERS PLEASE)
                                                                                                                 Recent
  Position Applied for ___________________________________                                                       Photo
  Surname                 ___________________________________
                                                                                                             Please sign back
  Forenames               ___________________________________                                                    of photo
  Maiden Name             ___________________________________
  Address                 ___________________________________
                          ___________________________________

  Telephone               ______________                           Mobile                         _________________
  Date of Birth           ______________                           Sex                            _________________
  Marital Status          ______________                           Nationality                    _________________
  Means of Transport ______________                                Driving License                _________________
  PPS Number              ______________                           An Bord Altranais              _________________
  Passport Number         ______________                           Email                          _________________

  Next of Kin

  Name                    ________________________________________________________
  Address                 ________________________________________________________
  Relationship            ____________________ Tel. No. ____________________________




 QUALIFICATIONS
                                  RGN                              RNID

                                  RSCN                             RPN

                                  RM                               Other       _______________
                                  (Active ______)



Form No: 184      Revision Status: 1



                                                               2
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Where applicable, indicate the duration of courses or experience in the following areas:

                                           Course       Experience   Duration/Comments

1.    A&E

2.    Burns/Plastic

3.    Cardio Thoracic

4.    CCU

5.    Computers

6.    ENT

7.    Geriatrics

8.    ICU (Adults)

9.    ICU (Paeds)

10. Infectious Diseases

11. Medical

12. Midwifery

13.   Neonates

14. Nephrology

15. Neurosurgery

16. Obstetrics/Gynae

17. Occ. Health

18. Oncology

19. Orthopaedics

20. Paediatrics

21. Phlebotomy

22. Psychiatry

23. Renal

24. Special Care (Babies)

25. Surgical

26. Theatre / OR

27. OTHER



Form No: 184          Revision Status: 1




                                                    3
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Candidate Name:



EDUCATIONAL ACHIEVEMENTS
Please include second level and third level educational achievements:
  Dates              Educational                  Conferring   Course of        Qualification /
From / To             Institution                   Body         Study           Achieved




            Form No: 184     Revision Status: 1



                                                      4
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Candidate Name

DETAILED CAREER HISTORY –

Present Employment




Previous Employment




Previous Employment




   Form No: 184   Revision Status: 1




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Previous Employment




Previous Employment




PLEASE EXPLAIN ALL GAPS IN YOUR EMPLOYMENT




         Form No: 184   Revision Status: 1


                                             6
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                               NURSE ON CALL
AGENCY NURSES COMPETENCY

Name:________________________________________          1. Can perform without supervision
                                                       2. Would require some assistance
An Bord Altranais No:___________________________       3. No experience


                       SKILL                             1         2         3      COMMENT
CARDIOLOGY
Ischaemic Heart Disease
Pre & Post Coronary Angiography/Angioplasty
CARDIAC SURGERY
Pre & Post Coronary Artery By Pass Graft (CABG)
Pre & Post Valve Surgery
MEDICINE
Provide nursing care for the following patients:
Respiratory
Gastroenterology
Dermatology
Diabetes
Neurology
SURGERY
Pre & Post operative care of patients undergoing
the following surgery:
General
Gynaecology
Urology
Vascular
Plastic Surgery
Orthopaedic
Ophthalmic
Neurosurgery
ONCOLOGY
General oncology patients
Neutropenic Isolation
Patients Receiving Radiotherapy
Patients Receiving Chemotherapy
INTENSIVE THERAPY UNIT
Ventilated patients
Cardiac Surgery
Neurosurgery
General Surgery
Vascular Surgery
Post cardiac or respiratory arrest
Multi organ system failure

Signed: _____________________________                  Date:________________________

Form No:    160       Revision Status: 1




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NAME : _______________________________________                           DATE : _______________
MEDICAL HISTORY
FILL-OUT THIS FORM PROPERLY. IF YOU ANSWER YES TO ANY OF THE FOLLOWING,
PLEASE GIVE DETAILS.

                                                                    YES NO              DETAILS
Have you had or are you due to have an operation ?


Have you ever suffered from any diseases / conditions of :
 The brain or the nervous system e.g. fainting spells, fits or
       seizures, depression or panic attacks or any form of
       psychiatric illness?
  The Throat or respiratory system e.g. bronchitis, asthma

The heart or circulatory system : e.g. abnormal blood pressure,
      varicos veins, heart trouble

The stomach, liver,bowels e.g. appendicitis, indigestion,
       stomach pain or ulcer

  Kidney or bladder trouble
The glandular system or blood : e.g. diabetes, anaemia,
      goitre, enlarged glands

Problems on the skin, ears, eyes, muscles, back or joint pains

Have you ever had TB?
When was your most recent Mantoux test?
What were the results?

Are you on any medications ?
Have you attended or have been advised to attend for treatment of
tests ( including blood tests ) within the last 2 years ?

Do you have allergies ?

Have you had X-ray examination or other specialized test like
ECG, EEG, etc. ? If yes, pls specify date and result.
Have you suffered from any illness not listed above ?

Are you pregnant? Please give due date?


I DECLARE THAT THE ABOVE STATEMENTS ARE TRUE AND COMPLETE TO THE BEST OF MY
KNOWLEDGE AND BELIEF.

SIGNATURE : _______________________________ Form No:                     138   Revision Status: 1

Form No: 138         Revision Status: 2




                                                             8
                                                                                 REF NO:




                                     NURSE ON CALL


                                            THIRD SCHEDULE

DECLARATION

(To be completed by agency nurses / carers)

I, ___________________________ of ____________________________,                    __________
       (Name)                               (Address)                                (DOB)

HEREBY DECLARE that:

I have never been arrested for, or convicted of, any offence or crime (other than an offence under
road traffic legislation), either in Ireland or in any other state;

I have never been the subject of a pardon or amnesty or other similar legal action in respect of any
offence or crime (other than an offence under road traffic legislation for which a penalty of
imprisonment is not enforceable);

I have never unlawfully distributed or sold a controlled substance (drug).

I am not currently nor have I ever been to my knowledge under investigation by the Garda Siochana /
Police force of any state in relation to the commission of a crime (other than an offence under the
road traffic legislation for which a penalty of imprisonment is not enforceable);

I am not currently nor have I ever been the subject of disciplinary action by any professional or
statutory body with responsibility for regulation of nursing or medical professions.

I hereby authorise the Hospital and / or its relevant Health Service Executive to make enquiries, for
the purpose of verifying any part if this declaration, with An Garda Siochana and / or the regulatory
body of nursing or medical professions of any state. This data will be processed by the Hospital and
the Agency in accordance with the Data Protection Acts, 1988 and 2003.


Signed



__________________________                                  Date___________________

Form No: 21     Revision Status: 2
Form No:       21      Revision Status: 1




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                                                          REF NO:




                               NURSE ON CALL



To Whom It May Concern:


I ________________________________________________give
                   (print name)


Nurse On Call / Carers and Nurses Aides On Call permission to check all
documents, letters, references, passports and immigration cards with the
appropriate authorities.




Signed: _________________________________

Date: _________________




Form No: 20    Revision Status: 2
Form No:      20     Revision Status: 1




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                                                                              REF NO:




                                 NURSE ON CALL
                            59 Ranelagh, Dublin 6 Tel: 4965199 Fax: 4965690



PERSONAL DETAILS

Name:                  ____________________________________

Address                ____________________________________

                       ____________________________________

Tel. No:               ____________________________________

PPS No:                ____________________________________


BANK DETAILS

Bank Account Name:                         ____________________________

Bank Account Address: ____________________________

                                           ____________________________

Bank Account No:                           ____________________________

Sorting Code:                              ____________________________


Form No:
Form No: 19    Revision Status: 2
              19      Revision Status: 1




                                                 11
                                                                               REF NO:




                                  NURSE ON CALL


    I give Nurse On Call/Carers and Nurses Aides On Call permission to use my date of birth
     I give Nurse On Call permission to use my date of birth when verifying my
    when verifying my registration by email with An Bord Altranais.
     registration by email with An Bord Altranais.




                                     (Print name & sign)




     Date of Birth: ____________________                   ABA Pin: ___________________




Form No: 161     Revision Status: 2
 Form No:    161        Revision No: 1




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                                                                                                    REF NO:




                                                               50 Patrick's Street, Cork, Ireland
                                                 Tel: (353) 21 422 2830 Fax: (353) 21 427 9939
                      Internet: http://www.nurseoncall.ie Email: nurseoncallcork@ireland.com




To Whom It May Concern:

I am aware that I am responsible for ensuring that my Manual Handling, Non Violent Crisis
Intervention Training and CPR are kept up to date.

I am also aware that I am personally responsible for ensuring that I am immunised against Hepatitis
B & C, Measles, Mumps, Rubella, Varicella (Chicken pox) and Tuberculosis. I will keep a regular
check on my antibodies level and that I will not put anyone at risk by not doing so.

I declare that I will never make myself available for work if I am sick or I am on sick leave from any
other establishment.

I am aware of my obligations under the Working Time Act and I am also aware that if I am
employed by another authority that they will be informed and that I am seeking extra hours with
Nurse On Call / Carers and Nurses Aides On Call.

I am also aware that my main employer has the right to ask Nurse On Call / Carers and Nurses Aides
On Call for a list of my hours worked through Nurse On Call / Carers and Nurses Aides On Call.




Name:_________________________________________

Signature: _____________________________________

Qualification:

Date: __________________________________________



Form No: 182    Revision Status: 1




                                                          13
                                                                                    REF NO:




                                     NURSE ON CALL
NURSE / CARER
I confirm that the interviewer                                                 has explained the
importance of the following to me:

                                                 Candidate initials      Interviewer initials

Health Check form completed

Drug Administration

Manual Handling, NVCIT & CPR up to date

Vaccinations

Uniform

Infection & Prevention Control understood

Garda Clearance requirement

Hospital Policies being adhered to

Mobile Phones off

Health & Safety Statement read

Timesheets Authorised

Time Keeping

Smoking Policy

I.D. badges

Risk Assessment done

Nurse must have their An Bord Altranais
with them at all times at work

Hepatitis C. Please be aware that you are obliged to inform Nurse on Call if
you have been in any high-risk situation.
I have discussed this with the Nurse Interviewer.

B.C.G. (Bacillus Calmette-Guerin)
Scar visible to Nurse Interviewer.
YES                 NO



Signature:                                               Date:


Form No: 137       Revision Status: 2
Form No: 137     Revision Status: 1



                                                14
                                                                                               REF NO:




                                                          50 Patrick's Street, Cork, Ireland
                                            Tel: (353) 21 422 2830 Fax: (353) 21 427 9939
                 Internet: http://www.nurseoncall.ie Email: nurseoncallcork@ireland.com




 Declaration for all Registered Nurses, Student Nurses, Health Care Assistants
 and Carers who are signing up for shifts with Nurse On Call / Carers & Nurses
                                  Aides On Call


   1. I accept that I am not employed by “Nurse On Call” / “Carers & Nurses Aides On Call”
      and will not become an employee of “Nurse On Call” / “Carers & Nurses Aides On
      Call” by virtue of carrying out any assignments that “Nurse On Call” / “Carers & Nurses
      Aides On Call” may find me. I understand that any payments made to me by “Nurse
      On Call” / “Carers & Nurses Aides On Call” are made on behalf of the client and shall
      not give rise to the creation of an employee/employer relationship between me and
      “Nurse On Call” / “Carers & Nurses Aides On Call”.

   2. I am aware that “Nurse On Call” / “Carers & Nurses Aides On Call” is not responsible
      or legally liable should any accidents or misdemeanours happen to me or should they
      arise out of the performance of my professional duties. I take personal responsibility
      that my professional indemnity insurance is up to date at all times and that I am
      immune/vaccinated against Hepatitis B, C, Mumps, Measles, Rubella and Varicella.

   3. I am aware that 3 references will be sought to assess my suitability for positions with
      “Nurse On Call” / “Carers & Nurses Aides On Call”.

I agree to abide by the above terms and I confirm that the information which I supply and the
statements which I have made above are true and correct.



Signed __________________________                                         Date ________________

        __________________________
               Printed Name




Form No: 183   Revision Status: 1




                                                           15
                                                                                               REF NO:




                                                          50 Patrick's Street, Cork, Ireland
                                            Tel: (353) 21 422 2830 Fax: (353) 21 427 9939
                 Internet: http://www.nurseoncall.ie Email: nurseoncallcork@ireland.com




 Declaration for all Registered Nurses, Student Nurses, Health Care Assistants
 and Carers who are signing up for shifts with Nurse On Call / Carers & Nurses
                                  Aides On Call


   1.
   4. I accept that I am not employed by “Nurse On Call” / “Carers & Nurses Aides On Call”
      and will not become an employee of “Nurse On Call” / “Carers & Nurses Aides On
      Call” by virtue of carrying out any assignments that “Nurse On Call” / “Carers & Nurses
      Aides On Call” may find me. I understand that any payments made to me by “Nurse
      On Call” / “Carers & Nurses Aides On Call” are made on behalf of the client and shall
      not give rise to the creation of an employee/employer relationship between me and
      “Nurse On Call” / “Carers & Nurses Aides On Call”.

   2.
   5. I am aware that “Nurse On Call” / “Carers & Nurses Aides On Call” is not responsible
      or legally liable should any accidents or misdemeanours happen to me or should they
      arise out of the performance of my professional duties. I take personal responsibility
      that my professional indemnity insurance is up to date at all times and that I am
      immune/vaccinated against Hepatitis B, C, Mumps, Measles, Rubella and Varicella.

   3.
   6. I am aware that 3 references will be sought to assess my suitability for positions with
      “Nurse On Call” / “Carers & Nurses Aides On Call”.

I agree to abide by the above terms and I confirm that the information which I supply and the
statements which I have made above are true and correct.



Signed __________________________                                         Date ________________

        __________________________
               Printed Name


Form No: 183   Revision Status: 1




                                                           16
                                                                              REF NO:




  OFFICE USE – Checklist
                                                                         Initials/Comments
Work Authorisation     Original Seen              Copy Taken          ___________________
Passport               Original Seen              Copy Taken          ___________________
An Bord Altranais Cert.Original Seen              Copy Taken          ___________________
NVCIT                  Original Seen              Copy Taken          ___________________
                       To Do Course with NOC
Manual Handling        Original Seen              Copy Taken          ___________________
                       To Do Course with NOC
CPR                    Original Seen              Copy Taken          ___________________
                       To Do Course with NOC
Garda Clearance        PPS Number                 Bank A/C details    ___________________
Tax Credit Cert.       P45 Received               ID card issued      ___________________
IV Study (within DATHs / HSE) ________________________ Vaccinations ______________________

References                                           Poor    Average   Good      Excellent
1st reference             Sent       Received
2nd reference             Sent       Received
 rd
3 reference               Sent       Received
Reason for seeking position _____________________________________________________________
Availability ___________________________________________________________________________


INTERVIEW SCORING


                Criteria                        Score                         Total

Educational Attainments                                                       10%

Required Qualifications                                                       20%

Extra Courses                                                                 20%

Experience                                                                    20%

Ability to Communicate Effectively                                            20%

Enthusiasm for Position                                                       10%

                TOTAL                                                         100%



Interviewed by:                                      Date:



Checked by:
Interviewed by:                                      Date:



Form No: 184    Revision Status: 1



                                                17
                                                                                         REF NO:




                                                    50 Patrick's Street, Cork, Ireland
                                      Tel: (353) 21 422 2830 Fax: (353) 21 427 9939
           Internet: http://www.nurseoncall.ie Email: nurseoncallcork@ireland.com




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                                                     18
                                                                                                  REF NO:




                                                             50 Patrick's Street, Cork, Ireland
                                               Tel: (353) 21 422 2830 Fax: (353) 21 427 9939
                    Internet: http://www.nurseoncall.ie Email: nurseoncallcork@ireland.com




                           OCCUPATIONAL HEALTH CHECKLIST


Candidate Name:              ______________________________________


I, __________________________________, candidate’s name confirm that I will complete
all the following HSE medical/occupational requirements before I commence any agency
shifts.

For All Posts
A Completed Confidential Health Declaration to include the following:


   N   BCG Records (if available in country of origin)
   N   Recent Heaf/Mantoux Test
   N   HBSag (surface antigen level)
   N   Hepatitis B Core antibody (Anti-Hep B c)
   N   Hepatitis B Surface Antibody
   N   Hepatitis C Antibody
   N   Immunisation records to include Diptheria, Tetanus & Polio
   N   Measles IgG and IgM
   N   Mumps IgG and IgM
   N   Rubella IgG and IgM
   N   Varicella IgG and IgM


I have been made aware of the Occupational Health Policies pertaining to the Irish
Healthcare setting.



Signed:        _____________________________                                 Candidate Signature
                                                                             Date:


Form No: 185     Revision Status: 1




                                                              19
                                                                                                REF NO:


                                  OCCUPATIONAL HEALTH SERVICE

                             CONFIDENTIAL HEALTH DECLARATION
 Pre-placement assessment aims to ensure so far as is possible that you are fit for the post for which you have applied. The
 contents of this form will remain confidential to the Occupational Health Service and will not be revealed to anyone else
 without your written consent.
 This questionnaire forms part of the appointments procedure and failure to declare a health problem or giving false
 information can result in the termination of your employment. A disability or health problem does not preclude
 consideration for the job and applications from suitable people with disabilities are welcome

  Post Applied For:                                             Personnel Officer/ Line manager:
  Location:
  Department:                                                   Proposed Start Date:


 Personal details:

 SURNAME:                                                     Other NAME(S):
 Date of Birth (dd/mm/yr):                                    Sex:              Male/Female

                                                              Previous name (if applicable):

 Address:

                                                              Telephone No:



 General Practitioner:
 Address:

                                                              Telephone No:




                                     PREVIOUS OCCUPATIONS - starting with present post
            JOB TITLE                                  EMPLOYER                                 FROM                TO




             PREVIOUS SICKNESS ABSENCE (time lost from work or school due to illness over last 2 years)
                  LENGTH OF ABSENCE                                   REASON FOR ABSENCE




Form No: 186         Revision Status: 1




                                                           20
                                                                                         REF NO:

PLEASE ANSWER YES OR NO AND IF YES, PLEASE GIVE DETAILS IN THE SPACE PROVIDED.
                                                                              NO   YES       DETAILS



1    Are you in good health at present?

2    Have you ever been treated in hospital ?

3    Have you ever suffered a work related illness or accident, or given up
     work because of ill health?
4    Do you smoke cigars/cigarettes/pipe/other?                                              If YES, how many per
                                                                                             week?
5    Do you drink alcohol?                                                                   If YES, how much per
                                                                                             week?
                                                                                                          Units
6    Are you having treatment of any kind at the moment?

7    Are you waiting for any treatment or investigation?

8    Have you been seen or examined by a doctor in the last 6 months?
9    Do you have any problem with your vision or your eyes?
10   Do you have any problems with your hearing or your ears?.
11   Do you have any physical limitation which may affect your ability to
     work?
12   Have you ever had any kind of back problem leading to time off
     work?
13   Have you ever had any kind of problems with your joints, including
     pain, swelling or restricted movements?
14   Do you have any difficulty in standing, bending, lifting or other
     movements?
15   Have you ever had any kind of skin problem?

16   Have you ever had diabetes, thyroid or gland problem?
17   Have you ever had seizures, blackouts or epilepsy?

18   Have you ever had asthma, bronchitis or chest problems?

19   Have you ever had Tuberculosis (TB)?

20   Have you had a cough for more than 3 weeks in the last 12 months?
21   Have you ever coughed up blood?

22   Have you had any unexplained loss of weight or fever in the last 12
     months?
23   Has any member of your family suffered from TB?

24   Have you ever had any mental illness?
25   Have you ever sought help for mental, psychological or emotional
     problems?
26   Have you ever had a drug or alcohol problem?

27   Do you have any allergies?

28   Have you ever had hepatitis or jaundice?


         Form No: 186         Revision Status: 1

                                                           21
                                                                                                REF NO:


 29      Have you ever received treatment for a gastric or bowel problem?

 30      Have you ever had heart circulation or blood pressure problems?

 31      Do you have any other medical condition?

 32      Disorder of the bladder or kidneys

 32      Have you ever been exposed to any of the following substances at work?:

         GLUTARALDEHYDE _____                 FORMALDEHYDE _____             CYTOTOXIC AGENTS                _____

         PAINTS/SOLVENTS _____                ASBESTOS           _____      NON-IONISING RADIATION _____

         OTHER ______________________________________________________________________________

 33      What is your height?                                                    What is your weight?
 34      Please list any sports/hobbies
 35      Do you have a BCG scar? (normally on the left upper arm)
 36      Have you ever had chickenpox?


 DECLARATION
 I declare that all of the above statements and information are true to the best of my knowledge and I understand that
 making a false declaration could lead to disciplinary action including the termination of my employment.

 SIGNATURE: ________________________________________ DATE: _______________________


 PRINT SIGNATURE:




 IMMUNISATION HISTORY;
 In order to protect you in your employment with the HSE, we routinely carry out a full
 immunisation review as part of pre-placement screening. To speed up the process and to ensure
 you have the required immunisations needed for your job, we ask that you complete the
 immunisation history where possible.
 In most cases your General Practitioner, previous occupational health service or community
 care department will have a record of your vaccination history.



Form No: 186       Revision Status: 1




                                                            22
                                                                                              REF NO:




                    IMMUNISATION/INVESTIGATION HISTORY
Please provide information regarding previous immunisations/investigations on the form below to the Occupational
Health Service of the HSE.
Have you ever had any of the following immunisations or tests? - Please indicate YES or NO and give dates and test
results where known.
IMMUNISATION                                  NO          YES        DATE                 TEST RESULT
TETANUS
POLIOMYELITIS
RUBELLA (German Measles)
TB Test (Heaf, Tine, Mantoux)
BCG (TB immunisation)
DIPHTHERIA
TYPHOID
MENINGITIS A & C
HEPATITIS A
MEASLES
IVS HEPATITIS C
HEPATITIS B:*see below
Injection No 1
Injection No 2
Injection No 3
Titre Level                                                                                     iu/l
Booster Dose
Titre following Booster                                                                         iu/l
VARICELLA Zoster
MUMPS

Exposure Prone Staff Categories include Doctors and Nurses applying for posts which would require them to work in
Theatres, Accident and Emergency, Anaesthetics, ENT, Radiodiagnosis, Obstetrics & Gynaecology, Dentists &
Paramedics.
* Information about Hepatitis B Status is essential for all Exposure prone posts (EPP). Please ensure that you supply
copies of titre results and that your GP or Occupational Health Service signs and stamps the form below.

I confirm that the information supplied above is correct to the best of my knowledge.

SIGNATURE: ________________________________________ DATE: ____________________

DESIGNATION: GP/ OHP/ OHN. _________________________________________________

                                   OFFICIAL STAMP of GP or OHS




                                                                                   Form No: 186        Revision Status: 1




                                                          23

								
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