Social Services Inspectorate
Medical declaration to be completed by the person in charge of a designated centre and by his/her general practitioners
The person named in Part 1 below is a person in charge of a designated centre under the Health Act 2007.The person in charge is the person with overall responsibility for the management of the centre.
Section 50 of the Health Act 2007requires 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 the person in charge provides a medical declaration pertaining to his/her physicaland mental health.
Part 1 is to be completed by the person in charge and then given to his/her general practitioner (GP). After the GP has completed Part 2, the GP is requested to forward the completed form to the Health Information and Quality Authority.
Part 1
To be completed by the person in charge.
Name of person in charge:Address:
Centre name:
Centre address:
Centre telephone number:
Centre email:
Is there anything in relation to your physical or mental health that may affect your ability to manage a designated centre?
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 (Person in charge): ______
Date:
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:
MedicalCouncil registration number:
Telephone number:
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 carry on the business of a designated centre?
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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