Criminal Records Declaration Form All applicants must complete this form in full and return it with their application form. Please refer to the guidance notes on the reverse of this form before completing the following sections. Name(Required) First Last Post applied for:(Required) Please answer the following questions:1. Have you ever been convicted by the courts or cautioned, reprimanded or given a final warning by the police? Please give details of offences, penalties and dates in the table below.* (Note that the post you have applied for is exempted under the Rehabilitation of Offenders Act (Exceptions Order) 1974, which means that all convictions, cautions, reprimands and final warnings on your criminal record need to be disclosed.(Required) Yes (Please provide details) No (Proceed to Q2) Date MM slash DD slash YYYY Details*If any circumstances change which would affect your response to this question, you must inform the Human Resources department of the details without unnecessary delay2. Have you ever been disqualified from work with children or vulnerable adults or subject to any other sanctions imposed by a regulatory body?(Required) Yes (Please provide details) No (Proceed to Q3) Date MM slash DD slash YYYY Details3. Are you registered with the Disclosure and Barring Service (DBS) Update Service?(Required) Yes No 4. Please sign the following declaration and return this form to Human Resources with your application for employment. Failure to complete this declaration will result in your application being withdrawn. I confirm that the information I have given on this form is correct and complete and I understand that any false information could result in my application being rejected or, if appointed, in my dismissal from employment. I understand that any offer of employment made to me will be subject to a further check with the Disclosure and Barring Service (previously Criminal Records Bureau) and I hereby give my consent for Coram to carry out the relevant DBS status checks in line with the DBS Code of Practice. I declare that I am not currently on the DBS Barred List and that I will notify the Human Resources department immediately if I do become barred in future. Date(Required) MM slash DD slash YYYY Signature(Required) Guidance Notes for Applicants Statement of commitment to safeguarding children and young people We are committed to safeguarding and promoting the welfare of children and young people, and expect all staff and volunteers to share this commitment. Why we need you to declare your criminal convictions and other related information The post you are applying for is exempt from the provision of Section 4(2) of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Orders 1975 and 2001 and therefore all convictions, cautions and bind-overs, including those regarded as ‘spent’, must be declared. We therefore ask you to complete the Criminal Records Declaration Form as fully as possible and return it with your application form. The only people who will see the information will be those directly involved in the recruitment process. All information will be handled in accordance with our Criminal Records Code of Practice. At interview, or in a separate discussion, we will ensure that an open and measured discussion takes place about any offences or other matter that might be relevant to the position. If you are successful at interview, we will require you to obtain an Enhanced Certificate of Disclosure from the Disclosure and Barring Service (DBS). Having a criminal record will not necessarily bar you from working with us. This will depend on the nature of the post you have applied for and the relevance and circumstances of your offences, as set out in our Criminal Records Code of Practice. We also comply with the Disclosure & Barring Service’s Code of Practice, which is available on their website at https://www.gov.uk/government/publications/dbs-code-of-practice. We ensure that anyone making appointment decisions has the necessary information and support to assess the relevance and circumstances of any offences. We also check whether you are barred from working with Adult and children in a regulated activity by the Independent Safeguarding Authority. It is a criminal offence for someone who appears on the Children’s Barred List to engage, or seek or offer to engage, in the regulated activity from which they are barred; your professional registration, if relevant; and that you are medically fit to undertake the role. False Information Please note that providing false information could result in your application being rejected or your dismissal from employment if you are appointed. The matter may also be referred to the police if we consider that you may have committed a criminal offence. Retention of Information The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 1998. It will only be used for the purpose of determining your application for this position. The declaration will be kept for no longer than necessary and then destroyed following receipt of a DBS Disclosure and a recruitment decision being made.
