Candidate and course provider declarations:
For completion by the candidate:
I declare that the work submitted for this practical application assessment i.e. the completed observation sheets and the report to management, is my own work. I recognize that contravention of this statement constitutes malpractice and may result in my being subject to the penalties set out in the NEBOSH Malpractice policy.

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Name (Print) ________________________________
Signature

________________________________

Date

______/______/________

For completion by a course provider representative
(e.g. internal practical assessor)
I declare that the work marked is identical to that received from the candidate. I recognize that contravention of this statement constitute malpractice and may result in my being subject to the penalties set out in the NEBOSH Malpractice policy.

Name (Print) _________________________________
Signature

_________________________________

Date

______/______/________

For completion by the course provider’s internal practical assessor: I declare that I have marked this work and am both qualified and approved by NEBOSH to do so. I recognize that contravention of this statement constitutes malpractice and may result in my being subject to the penalties set out in the NEBOSH Malpractice policy. Name (Print) __________________________________

Signature

__________________________________

Date

______/______/________

NB: This declaration must be completed in full, submitted and retained with the candidate’s script.
If this declaration is not submitted the candidate’s result may be declared void.

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