PROTECT-PERSONAL (when completed) BFG Form 33D

(Revised 09/13)

SAFEGUARDING VULNERABLE GROUPS PERSONAL INFORMATION REQUEST - FORM

DECLARATION OF CONFIDENTIAL INFORMATION

Applicant's Details
Position applied for
Surname / 0 / Forename(s)
Previous Name / 0 / Date of birth
MQ Address / 0 / Contact No.
(with Postcode)
0 / Place of Birth
(Town/County and Country)
Lived at present address since
Professional Registration Number, eg GSCC, DfEE (or other professional body if appropriate).
Name of awarding body
The amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are 'protected' and are not subject to disclosure to employers and cannot be taken into account.
Guidance and criteria on the filtering of these cautions and convictions can be found on the Disclosure and Barring Service website
Any additional information should be continued on the continuation sheet clearly identifying the question to which you are responding.
1. Do you have any convictions, cautions, reprimands or final warnings that are not "protected" as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)?
YES / NO / If YES, please give details
2. Are you subject to any pending prosecutions or current criminal investigations?
YES / NO / If YES, please give details
3. Are you disqualified from working with a vulnerable group, including children through a court imposed disqualification order or through your inclusion on the Disclosure and Barring Service Barred Lists? (previously known as the Department of Health or Department for Children, Schools and Families Lists of those barred from working with children or the PoCA Register)
YES / NO / If YES, please give details
4. Are you subject to any pending disciplinary action, complaints or investigations in your current employment that would affect your suitability to work with children or vulnerable persons?
YES / NO / If YES, please give details
5. Has a previous employer ever taken disciplinary action against you or have you been subject to a disciplinary investigation in respect of Safeguarding Children or Vulnerable persons?
YES / NO / If YES, please give details
6. Have you ever been dismissed by a previous employer?
YES / NO / If YES, please give details
7. Has a young person made an allegation against you involving abuse, malpractice or professional misconduct?
YES / NO / If YES, please give details
8. Have you OR a member of your family living with you OR a person not related to you but living in your home, been the subject of a child protection investigation or enquiry either currently or in the past?
YES / NO / If YES, please give details
9. Have you ever had a child for whom you had caring or parental responsibility removed from your care?
YES / NO / If YES, please give details
10. Have you ever had a child for whom you had caring or parental responsibility made subject of a Child Protection Plan or their names placed on the Child Protection Register?
YES / NO / If YES, please give details
11. Are you aware of any other circumstances that might affect your suitability to work or be in regular contact with children or vulnerable persons?
YES NO If YES, please give details
Date / Signed
CONTINUATION SHEET
Please complete stating question number and give further details.
Question / Further details.

PROTECT-PERSONAL (when completed)