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Self Disclosure Form
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IMPORTANT NOTICE:
Please DO NOT complete this form unless you have been asked to do so by HR or SMT.
Title
*
Mr.
Mrs.
Ms.
Dr.
Prof.
Mx.
Other
Full Name
*
First
Last
Previous Names
First
Middle
Last
Preferred Name
Please include date(s) each name was used (MM/YYYY)
Phone
*
Date Of Birth
*
Gender
*
As the role you have applied for involves contact with children, you will also be required to undergo the relevant vetting and barring checks.
Depending on the nature of the role, this could include checking criminal convictions and checking that you are not barred from working with children. All information you provide will be treated as confidential and managed in accordance with relevant data protection legislation and guidance. You have a legal right to access any information held about you.
Have you ever been known to any Children’s Services department or police as being a risk or potential risk to children?
*
Yes
No
If yes, please provide further information:
*
Have you been the subject of any investigation and/or sanction by any organisation or body due to concerns about your behaviour towards children?
*
Yes
No
If yes, please provide further information and include details of the outcome:
*
Have you ever been the subject of disciplinary sanctions or been asked to leave employment or voluntary activity due to inappropriate behaviour towards children?
*
Yes
No
If yes, please provide further information:
*
Do you have any unspent convictions in the UK or overseas?
*
Yes
No
If yes, please provide further information:
*
Confirmation of declaration
(tick box below)
I agree that the information provided here may be processed in connection with recruitment purposes and I understand that an offer of employment may be withdrawn or disciplinary action may be taken if information is not disclosed by me and subsequently come to the organisation’s attention.
*
I agree
In accordance with the organisation’s procedures if required I agree to provide a valid criminal record certificate and consent to the organisation clarifying any information provided on the disclosure with the agencies providing it.
*
I agree
I agree to inform the organisation within 24 hours if I am subsequently investigated by any agency or organisation in relation to concerns about my behaviour towards children or young people.
*
I agree
I understand that the information contained on this form, the results of the criminal record check and information supplied by third parties may be supplied by the organisation to other persons or organisations in circumstances where this is considered necessary to safeguard children.
*
I understand
Signature of Candidate
*
Clear Signature
Print Name
*
Date:
*
Submit
