Self Declaration Form

    Self-declaration form for Standard/Enhanced DBS checks – England and Wales
    STRICTLY CONFIDENTIAL

    As an organisation we undertake to meet the requirements of the Data Protection Act 1998 and all other relevant legislation, and the expectations of the Information Commissioners Office relating to the data privacy of individuals.

    (*) Mandatory field

    A) CONVICTION HISTORY

    The amendments to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (2013 and 2020) provides that when applying for certain jobs and activities, certain convictions and cautions are considered ‘protected’. This means that they do not need to be disclosed to employers, and if they are disclosed, employers cannot take them into account. Guidance about whether a conviction or caution should be disclosed can be found on the Ministry of Justice website.

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

    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 (Amendment) (England and Wales) Order 2020?*

    If you answered yes to either of the questions above, please give details including the nature of the offences and the dates. It would be helpful to include details of the reasons and circumstances that led to the offence(s).

    B) Overseas History

    1) Have you ever lived, worked, or volunteered outside the United Kingdom?*

    If yes, please provide details, including the name of the country/countries:

    1) Do you have any overseas convictions?*

    If yes, please provide details, including the name of the country/countries:

    B) PAST CONDUCT

    1) To your knowledge have you ever had any allegation made against you, which has been reported to, and investigated by, Social Services/Social Work Department (Children’s or Adult Social Care)?*

    If yes, please give details below.

    2) Has there ever been any cause for concern regarding your conduct with children, young people, vulnerable adults? Please include any disciplinary action taken by an employer in relation to your behaviour with adults.*

    If yes, please give details below.

    B) DECLARATION

    To help us ensure that we are complying with all relevant safeguarding legislation, please read the accompanying notes and complete the following declaration.

    First Name* Last Name*

    Email*

    Declaration 1*

    I consent to an standard/enhanced DBS check for my volunteering role. I have read the Standard/Enhanced Check Privacy Policy for applicants. I understand how the DBS will process my personal data and the options available to me for processing an application. I am aware that if I am being asked to apply for an enhanced disclosure it will show spent and unspent convictions and adult cautions, from the Police National Computer which have not been filtered in line with legislation plus any information held by local police that’s considered relevant to the role. I am aware that, failure to disclose information that is not ‘protected’, could result in the withdrawal of approval to volunteer or work within Embracing Age. This process is subject to a strict code to ensure confidentiality, fair practice and security of any information disclosed. I agree to inform my line manager within Embracing Age if I am convicted of an offence after I take up any post within the organisation. I understand that failure to do so may lead to the immediate suspension and/or the termination of my volunteering or work. I agree to inform my line manager in Embracing Age if I become the subject of a police force and/or a social services/(Children’s Social Care or Adult Social Services)/Social Work Department investigation. I understand that failure to do so may lead to the immediate suspension or termination of my volunteering or work. PLEASE TYPE YOUR INITIALS BELOW. By entering your initials in the box below, you are effectively providing your signature, confirming your consent to the above.

    Initials*

    Declaration 2*

    Those applying for work with children and/or vulnerable adults in positions which fall within the scope of regulated activity please confirm that you are not barred from working with children/vulnerable adults.I confirm that I am not barred from working with children / vulnerable adults. By entering your initials in the box below, you are effectively providing your signature, confirming that you are not barred from working with children/vulnerable adults.

    Initials*
    Legalise

    The Disclosure of any offence may not prohibit volunteering. Please refer to our Equal Opportunities Policy. The amendments to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (2013 and 2020) provides that when applying for certain jobs and activities, certain convictions and cautions are considered ‘protected’. This means that they do not need to be disclosed to employers, and if they are disclosed, employers cannot take them into account. The DBS Service Code of Practice and our own procedures are available on request for you to read. It is stressed that a criminal record will not necessarily be a bar to appointment, only if the nature of any matters revealed could be considered to place children or vulnerable adults at risk. As an organisation we agree to abide by the Code of Practice on the use of personal data in employee/employer relationships under the General Data Protection Regulations, as well as the expectations of the DBS.