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DISCLOSURE OF RELATIONSHIPS – DECLARATION

The company recognises and values the fact that in some of the communities where it operates care
homes, multiple members of a family may be employed at the same, or adjacent sites. In many cases
friends, neighbours or other parties to relationships may also be employed. Also, it is not unusual for
relationships to develop between people working together.

In all of these situations, because it is common for employees to spend significant amounts of time
together outside work, the rules on confidentiality are even more important. Accordingly, employees
are required, as detailed in the Employee Handbook, to report in writing, in confidence to the Home
Manager, the details of any such relationship on the form provided.

All parties to the relationship must complete this form, which will be held on personnel files. Four
Seasons Health Care Group will treat any disclosed information with complete confidentiality.

You are reminded that you must not disclose to, or discuss with anyone, including someone from your
family or with whom you have a relationship, any information about residents, clients, patients,
colleagues or their families, unless required by law or as an accepted part of your normal duties.

Should such a relationship exist within the location, the Company will have discretion to deal with the
matter in whatever way it considers appropriate and reasonable in all the circumstances.

Declaration Staff Members name of whom the


relationship is with/ related to

I wish to inform the company that I have a


relationship with another member of staff.

I wish to inform the company that I am related to


another member of staff.

I am fully aware that I must not, without authorisation, discuss or disclose any personal information
about residents, clients, patients, colleagues and their families or matters relating to the Company’s
business.

Name:___________________________________________________________

Sign:____________________________________________________________

Date:____________________________________________________________

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