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Medical declaration for management FINAL 10 02 11

By Vivian Payne,2014-06-20 13:42
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Medical declaration for management FINAL 10 02 11

Health Information and Quality Authority

Social Services Inspectorate

Medical declaration to be completed by those

    involved in the management of designated centre

    and their general practitioners

    The person named in Part 1 below is involved in the management of a designated centre under the Health Act 2007.

    Section 50 of the Health Act 2007 requires that each of those persons involved in the provision and management of residential services is a fit person to do so. As part

    of the assessment of medical fitness, it is required that those involved in the management of a centre provide a medical declaration pertaining to their physical and mental health.

    Part 1 is to be completed by the person involved in the management of the designated centre and then given to his/her general practitioner. After the general practitioner has completed Part 2, the general practitioner is requested to forward the completed form to the Health Information and Quality Authority.

Part 1

    Part 1 is to be completed by the person involved in the management of the centre.

Name of person:

Position:

     Address:

Centre name:

    Centre telephone no.:

    Centre email:

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Is there anything in relation to your physical or mental health that may

    affect your ability to be involved in the management of a designated centre

    under the Health Act 2007?

Declaration

    Section 47 and Section 79(1)(b) of the Health Act 2007 make it an offence for a person to make a statement which is false or misleading in, or in respect of, an application for registration or renewal of registration

    I certify that the information provided is, to the best of my knowledge and belief, accurate and complete in every respect.

Signed: ___________________

Date:

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Part 2

Part 2 is to be completed by the general practitioner of the person named above and

    returned by the general practitioner directly to the Health Information and Quality

    Authority.

GP’s name:

     Address:

Medical Council

    registration

    number:

    Telephone

    number/s:

Email address:

1. How long have you known the person named above?

    2. Is there anything in relation to the person’s physical or mental health that may affect his/her ability to be involved in the management of a designated centre under the Health Act 2007?

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Declaration

    Thank you for completing this form. Please read and sign the declaration below.

    Section 47 and Section 79(1)(b) of the Health Act 2007 make it an offence for a person to make a statement which is false or misleading in, or in respect of, an application for registration or renewal of registration

    I certify that the information provided is, to the best of my knowledge and belief, accurate and complete in every respect.

Signed (general practitioner): _________________

Date:

Please return the completed form to:

Registration Section

    Health Information and Quality Authority

    Social Services Inspectorate

    Unit 1301

    City Gate

    Mahon

    Cork

    Please note: if any fee is payable in connection to this form, it should be discharged between the applicant and the general practitioner.

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