MCare NI

Community Care Assistant – Health Declaration Form

CCA 3 - Health Declaration Form

This is a Health declaration in respect of a prospective Domiciliary Care Assistant working in a Registered Domiciliary Care Agency.

The declaration of a disability, previous or current health condition will not prevent an applicant from working with children, unless indicated otherwise by a GP or Medical Adviser.  It is an employer’s responsibility to ensure reasonable adjustments, where practicable, are made under Disability Discrimination Act 1995 to enable an applicant to work in a community setting.

To be completed by the applicant.

Postal Code
Are you in good health?
Are you willing to undergo a medical examination, if required?
Have you ever suffered from, or do you currently suffer from any of the following?
Do you have any other illness not referred to above
Do you have any other illness not referred to above
Do you have any other pre-existing health related condition that would impact your ability to work in regulated activity?


I declare that the information given in this Health Declaration is, to the best of my knowledge and belief, complete and correct.


I understand that any information disclosed will be dealt with sensitively and in compliance with the Data Protection Act 1998.


Any information to be shared with a third party will be done with my prior knowledge and consent.


I undertake to notify MCare NI of any ill health which subsequently occurs.


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