Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Section B Please fully complete all relevant sections.

1. Do you have any unspent conditional cautions or convictions under the Rehabilitation of Offenders Act 1974? *

Yes

No

2. Do you have any adult cautions (simple or conditional) or spent convictions that are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013 and 2020)? *

Yes

No

3. Are you aware of any criminal/police enquiries/investigations undertaken following allegations made against you which may have a bearing on your suitability for the post? *

Yes

No

4. Are you at present the subject of any criminal/police enquiry/investigation/pending prosecution which may have a bearing on your suitability for the post? *

Yes

No

5. Is your role deemed “home based”, as per the DBS definition? *

Yes (proceed to Question 6.)

No (proceed to Question 8.)

6. If you are working from home with children, is there anyone who is 16 years of age or over living or employed in your household who has any unspent conditional cautions or convictions under the Rehabilitation of Offenders Act 1974 and/or any adult cautions (simple or conditional) or spent convictions that are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013 and 2020)? *

Yes

No

N/A

7. If you are working from home with children, is there anyone who is 16 years of age or over living or employed in your household who is at present the subject of a criminal/police enquiry investigation/pending prosecution? *

Yes

No

N/A

8. Have you lived, worked or volunteered outside the United Kingdom for a continuous period of six months or more at any point within the previous 10 years? *

Yes

No

9. Does your role involve engaging in regulated activity with children? *

Yes (proceed to Question 10.)

No (proceed to Question 11.)

10. Are you or have you ever been barred from work with children? *

Yes

No

N/A

11. Does your role involve regulated activity with vulnerable adults? *

Yes (proceed to Question 12.)

No (proceed to Question 13.)

12. Are you or have you ever been barred from work with vulnerable adults? *

Yes

No

N/A

13. Are you currently or have you ever been subject to any formal action as a result of an allegation that your conduct has amounted to, resulted in or put a child and/or vulnerable adult at risk of harm? *

Yes

No

14. Are you currently or have you ever been subject to a court order either made against you or in relation to you that you have caused harm to a child and/or vulnerable adult, or that a child and/or vulnerable adult was at risk of harm from you? *

Yes

No

15. This question must be answered in relation to circumstances that have arisen from a child/ren being in your care. If you are an adoptive and/or foster parent and the circumstances either relate to the child/ren’s previous situation, or to the removal/placement/child protection or child in need plan, which formed part of the planned management or transition of the child/ren into your care, then you do not need to answer yes to this question. Has a child/ren in your care or for whom you have or had parental responsibility ever been removed from your care, placed by you in care and/or been made subject to a child protection or child in need plan as a result of a safeguarding concern that has arisen whilst the child/ren has been in your care and/or in relation to your provision of their care? *

Yes

No

16. Is there any other information that may be considered relevant to the questions in this Confidential Declaration Form, and which may have a bearing on your suitability for the post you are applying for, (i.e. working with children and/or vulnerable adults)? *

Yes

No

Declaration: I declare the above information is true, accurate and complete to the best of my knowledge. After I have been appointed and during my appointment, I agree to inform the responsible person immediately if my answers to any of the above questions change and provide the relevant details.

Signed *

Electronic signature is permitted

First Name

Last Name

Date *

MM

DD

YYYY

Consent statement (this statement should only be signed if the answer to Question 8. is Yes) I consent to my details being transferred outside the UK for the purposes of an overseas criminal records check.

Signed

Electronic signature is permitted

First Name

Last Name

Date

MM

DD

YYYY