N.B. Please only complete this section if you will be performing Exposure Prone Procedures (EPPs). Exposure Prone Procedures (EPP) are those procedures where the worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissue (eg spicules of bone or teeth) inside a patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times.

Documentary evidence of hepatitis B and C and HIV status is required for staff undertaking EPP for the first time. If you have previous blood results and/or documented evidence of relevant vaccinations, please supply a copy when you submit this form. If results are not available you will be tested in this department before clearance can be given. This must be an identified validated sample (IVS) as required by the Department of Health, so you will need to bring with you photographic ID, e.g. driver’s licence or passport.

Under the Data Protection Act 1998 the information you supply in this form is known as sensitive personal data. Before we are able to process sensitive personal data your consent is required. By signing this declaration, you will be giving your consent to the processing of the information you have supplied and management being informed of your fitness for employment.

I confirm that I have read and understood the Data Protection information above. I declare that all the foregoing statements are true and complete to the best of my knowledge and belief.

I confirm that I agree to allow Reliance Ambulance Service Ltd to share information concerning my immunisations and immunity to infection with the appropriate manager/tutor to enable an Infection Control risk assessment to be undertaken where required.

I understand that if further information is required from my GP or other health professional, I shall be contacted by Reliance Ambulance Service Ltd to obtain my fully informed consent before any report is requested.