Health - non regulated service providers declaration

1. Business name *

2. Business address including postcode *

3. Name of accountable manager *

4. Job title of accountable manager *

5. Business contact number *

6. Business email address *

7. Are you a sole trader? *

Yes
No

8. Do you have employers liability insurance (not required if you are a sole trader)? *

Yes
No

9. If you have employers liability insurance, how much cover do you have?

10. Employers liability insurance expiry date

11. Do you have public liability insurance? *

Yes
No

12. How much public liability insurance cover do you have?

13. Public liability insurance expiry date

14 Do you and / or your staff use their personal vehicles in the course of their work? *

Yes
No

15. Are those using personal vehicles for work insured for “Social, domestic and pleasure including business use”? *

Yes
No
Don't know

16. Do you maintain the relevant standards to assure safeguarding of vulnerable adults, including satisfactory enhanced Disclosure Barring Service checks for staff (and volunteers) in contact with, or accessing data about, vulnerable adults? *

Yes
No

17. Do you have procedures in place to responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of individuals who access your service? *

Yes
No

18. Can you confirm that basic training on the prevention of abuse and self-neglect is given to all staff and volunteers within three months of employment commencing and/or engagement in activities with individuals? *

Yes
No

19. Do you have a Whistleblowing policy which includes procedures under which staff and volunteers can raise, in confidence, any serious concerns that they may have and do not feel that they can raise in any other way? *

Yes
No

20. In the last three years have you had any finding of unlawful discrimination made against your organisation by an Employment Tribunal, an Employment Appeal Tribunal or any other court (or in comparable proceedings in any jurisdiction other than the UK)? *

Yes
No

21. If "Yes", please provide details

22. In the last three years have you had any complaints upheld following an investigation by the Equality and Human Rights Commission or its predecessors (or a comparable body in any jurisdiction other than the UK), on grounds of alleged unlawful discrimination. )? *

Yes
No

23. If "Yes", please provide details

24. Have you been convicted of breaching environmental legislation, or had any notice served upon you, in the last three years by any environmental regulator or authority (including local authority)? *

Yes
No

25. If "Yes", please provide details

26. Do you comply with the Health and Safety at Work Act etc. 1974? *

Yes
No

27. Will you notify Carers' Support East Kent of any safeguarding and risk concerns that we may have? *

Yes
No

28. I can supply documentary evidence of insurances upon request *

Yes
No

29. I confirm that I am authorised to provide this information on behalf of our organisation, that the information given is correct, and that I will notify Carers’ Support East Kent of any changes to the above as they happen. *

Yes
No

30. Please tick to confirm that you have read and understood our privacy notice *

I have read and understand the privacy notice.

Read our privacy notice here (this will open in a new window to avoid losing data already filled in) - https://carersek.org.uk/privacy-notice/

Health – non-regulated service providers declaration

Please complete the form below to help us understand if we can refer clients to your for services that you provide.