SECONDARY EMPLOYMENT DECLARATION (HR-F020) Contact SECONDARY EMPLOYMENT DECLARATION Secondary Employment Declaration & Dual-Role Risk Assessment (HR-F020)SECTION 1: EMPLOYEE BASELINE DATATitle- Select -MrMrsMissMsMxOtherStaff Member NameStaff_IDJob TitleCare Worker / Support WorkerComplex Care WorkerSenior Care Worker / MentorField SupervisorCare Coordinator / Rota SchedulerClinical LeadQuality Assurance / Compliance OfficerHR / Recruitment AdministratorImplementation ResearcherDeputy Care ManagerRegistered Care ManagerOperating Local Authority- Select -HaringeyIslingtonBarnetWaltham ForestCamdenHackneyBrentHarrowRedbridgeNewhamCity of LondonWestminsterTower HamletsBarking and DagenhamHaveringKensington and ChelseaHammersmith and FulhamEalingHillingdonHounslowSouthwarkLambethLewishamGreenwichWandsworthRichmond upon ThamesMertonKingston upon ThamesSuttonBexleyBromleyCroydonOtherDo you currently hold, or intend to take up, any other paid or unpaid work (including 'bank' work, self-employment, or gig economy roles)?- Select -YesNoN/ASECTION 2: DETAILS OF SECONDARY EMPLOYMENT, CUMULATIVE FATIGUE & WTR COMPLIANCEPrimary Sector of Secondary Employer- Select -NHS Trust / Primary Care (GP/Hospital)Residential / Nursing Care HomeAnother Domiciliary Care AgencySupported Living / Day CentreGig Economy / Delivery (e.g., Uber, Deliveroo)Retail / Hospitality / General AdministrationSelf-Employed / Private Business OwnerAverage Weekly Hours in Secondary RoleTypical Shift Pattern- Select -Waking Nights (High Fatigue Risk)Sleep-insStandard Day ShiftsEvening / Twilight ShiftsVariable / Zero-Hours (Unpredictable)48-Hour Threshold Check- Select -Total exceeds 48 hours; HR-F019 Working Time Directive Opt-Out Agreement is signed and active.Total remains strictly under 48 hours; Opt-Out not required at this time.Total exceeds 48 hours; HR-F019 Working Time Directive Opt-Out Agreement is signed and active.Total remains strictly under 48 hours; Opt-Out not required at this time.The 11-Hour Daily Rest Mandate- Select -I explicitly confirm my combined shifts allow for 11 consecutive hours of rest in every 24-hour period. I will never undertake a Mutima Care shift immediately following an external night shift.I cannot guarantee 11 consecutive hours of rest; formal management review and rota adjustment required.Rota Submission- Select -I formally agree to provide my secondary employer's rota/schedule upon request to Mutima Care management to verify statutory safety limits.SECTION 3: INFECTION PREVENTION, CONTROL, CONFLICT OF INTEREST & DIGITAL INTEGRITYIs the secondary setting currently under 'Infectious Disease Surveillance' or 'Enhanced IPC Measures' (e.g., COVID-19, Norovirus, MRSA)?- Select -YesNoUnknownN/AHigh-Risk Clinical Environments: Does your secondary role involve working in an Intensive Care, Infectious Disease, or Acute Clinical ward?- Select -Yes - Extremely High IPC RiskNo - Standard/Community EnvironmentN/AOutbreak Notification- Select -I explicitly agree to notify Mutima Care immediately if an infectious outbreak occurs at my secondary workplace, BEFORE attending my next domiciliary visit.Direct Competition: Is your secondary employer a competitor in our local authority areas?- Select -Yes - Direct Competitor (Triggers formal Non-Solicitation Review)No - Not a direct competitorN/ANon-Solicitation- Select -I legally acknowledge my contractual duty not to solicit, recruit, or advertise my secondary services to any Mutima Care service users or staff members.SECTION 4: MANAGER’S RISK GRADING (Internal Use Only)Digital AssetsI confirm I will never share, copy, or use Mutima Care's proprietary digital care plans, workflows, or Nourish/Birdie templates within my secondary organisation.Cumulative Fatigue Risk- Select -LowMediumHigh (Night Worker)IPC Cross-Contamination Risk- Select -LowMediumHigh (Acute Clinical)Conflict Risk- Select -LowMediumHigh (Direct Competitor)MultiselectNo 07Maximum weekly hours cap hard-coded into Rostering System.Exclude from 'High-Complexity' or time-critical Medication calls due to fatigue risk.No mitigations required.Final Decision- Select -Approved - No operational mitigations required.Approved - Rota mitigations formally applied and locked.Declined - Cumulative fatigue poses an unacceptable risk to clinical safety.Declined - Unacceptable Conflict of Interest / Commercial Risk.SECTION 5: FINAL DECLARATIONS & AUTHORISATIONContracted Hours at Mutima CareEmployee Declaration- Select -I confirm the accuracy of this data. I understand that failing to report secondary employment or changes in hours is a breach of safety and may result in disciplinary action under Gross Misconduct.Manager / HR LeadDateNext Review Date:SUBMIT FORM
