CONFIDENTIAL SELF DECLARATION FORM
NAME: / POSITION APPLIED FOR:
PARISH:
Under the terms of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, the personsyou will be working with include children and/or vulnerable adults. This means that you are exempt from the Act and will be asked to declare any previous criminal convictions including ‘spent’ convictions. This information can then be used as a basis for deciding whether or not you are suitable to work with children and vulnerable adults. The disclosure of an offence will not necessarily be a bar to your appointment. However, failure to disclose an offence or other misrepresentations may result in the termination of your services.
This form is strictly confidential and, except under compulsion of law, will be seen only by those
responsible for your appointment and in certain circumstancesthe Diocesan Director for Safeguarding and Inclusion. Allforms will be kept securely under the terms of the Data Protection Act 1998.
Please tick either the YES or NO Box in answer to EVERY QUESTION
1a / Have you ever been convicted of a criminal offence (including any spent convictions under
the Rehabilitation of Offenders Act 1974)?
YES /  / NO / 
If yes, please state the nature and date(s) of the offence(s), continuing on a separate sheet if necessary.
1b / Have you ever been cautioned by the police, given a reprimand or warning or bound over to
keep the peace?
YES /  / NO / 
If yes, please state the nature and date(s) of the offence(s), continuing on a separate sheet if necessary.
1c / Are you at present under investigation?
YES /  / NO / 
If yes, please give full details continuing on a separate sheet if necessary.
1d / Have you ever been found by a Court exercising Civil Jurisdiction (including matrimonial or
family jurisdiction) to have caused significant harm to a child or young person under the
age of 18 years, or has any such Court made an Order against you on the basis of any findingor allegation that any child, young person or vulnerable adult was at risk of significant harm from you?
YES /  / NO / 
If yes, please give full details continuing on a separate sheet if necessary.
2a / Has your conduct ever caused or been likely to cause significant harm to a child or young
person under the age of 18, or put a child or young person at risk of significant harm?
YES /  / NO / 
2b / Has your conduct ever caused or been likely to cause significant harm to a vulnerable adult,
or put a vulnerable adult at risk of significant harm?
YES /  / NO / 
If yes, please give full details continuing on a separate sheet if necessary.
2c / To your knowledge, has it ever been alleged that your conduct has resulted in any of the things mentioned at 2a and 2b above?
YES /  / NO / 
If yes, please give details, including the date(s) and nature of the conduct, or alleged conduct, andwhether you were dismissed, disciplined, moved to other work or resigned from any paid or voluntary work as a result.
If necessary please continue on an additional sheet.
3 / Has a child in your care or for whom you have or had parental responsibility ever been
removed from your care, been placed on the Child Protection Register or been the subject of aCare Order, a Supervision Order, a Child Assessment Order or an Emergency ProtectionOrder under the Children Act 1989, or a similar Order under other legislation?
YES /  / NO / 
If yes, please give full details, continuing on a separate sheet if necessary.
4. / Has your name been placed on the list of those barred from working with children, young people or vulnerable adults?
YES /  / NO / 
4.a / If yes which List?ChildrenVulnerable Adults
5. / Are you, or is anyone living at the same address as you, a Registered Sex Offender?
YES /  / NO / 
If yes please give full details, continuing on a separate sheet if necessary
6. / Have you, since the age of 18, ever been known by any names other than that given below?
YES /  / NO / 
If yes, please give full details, continuing on a separate sheet if necessary.
7. / Have you any health problem(s) which might affect your work with children or young people
under the age of 18 or vulnerable adults?
YES /  / NO / 
If yes, please give full details , continuing on a separate sheet if necessary
8. / Have you during the past 5 years, had any home address other than that given below?
YES /  / NO / 
If yes, please give full details, continuing on a separate sheet if necessary.
9. / Is there anything else you would like to declare? Yes  No 
If yes, please give full details, continuing on a separate sheet if necessary.
DECLARATION
I declare that the above information (and that on the attached sheets ***) is accurate and complete to
the best of my knowledge.
Signed ...... Date ......
Full Name ...... Date of Birth ......
Address ......
...... Postcode ......
Tel. No...... Email ......
*** please delete if not applicable
Please return the completed form to:
This appointment is / is not subject to an Enhanced Disclosure fromthe Disclosure and Barring Service.

April 2013.

Notes for confidential declaration form.

Questions 1a and 1b – Declare all convictions, cautions, reprimands or warnings however old or whether you are at present under investigation by the police. Motoring offences that cannot be dealt with by a prison sentence need not be declared. Posts where the person is working or coming into regular contact with children, young people or vulnerable adults are exempt from the Rehabilitation of Offenders Act 1974. Convictions obtained abroad must be declared as well as those from the UK.

Question 1c– Declare if you are at present under investigation by the police, social services or an employer.

Question 1d - You must declare any finding by a civil court that your actions have significantly harmed a child, young person or vulnerable adult. Declare any court orders made on this basis.

Question 2a and 2 b– Make any statement you wish about any incident you wish to declare.

Question 2c – Declare any complaints or allegations made against you, however long ago, that you have significantly harmed a child, young person or vulnerable adult. Any allegation or complaint which has been investigated by police, Children’s or Adult Services, an employer or voluntary body must be declared. Checks will be made with the relevant authorities.

Question 3 – all these matters will be checked with the relevant authorities.

Question 7 – please declare in confidence any health problems that may affect your ability to work with children, young people or vulnerable adults. This question is primarily intended to help you if you subsequently need to withdraw from work with children, young people or vulnerable adults because of a recurring health problem.

Some of the information requested on the form will be checked with the Disclosure and Barring Service. All information requested will be carefully assessed to decide whether it is relevant to the post applied for and will only be used for the purpose of protecting children, young people or vulnerable adults,

Use of Confidential Declaration

In accordance with the Disclosure and Barring Service code of practice great care must be taken to ensure that those with criminal convictions are not discriminated against. Background information should only be taken into account if it is relevant to the position sought. The DBS advise that anyone seeking and appointment with children, young people or vulnerable adults should be given an early opportunity to declare any relevant matters. The Confidential Declaration Form should be used for this purpose. Information declared will either be checked with the DBS or with other relevant authorities. A conferential declaration must be held by the person who makes the appointment.

April 2013