CORTH EMPLOYEE + APPLICANT DBS DECLARATION FORM

Please read the information below before completing this form.

The job you have applied for/currently undertake is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 ((Exceptions) Order 1975). This means you are not entitled to withhold information about convictions which for other purposes are “spent” under the Act, except those excluded from the DBS filtering guidance rules (see attached).

If you fail to complete this form, or if you provide false information or fail to disclose convictions which you are required to disclose, this could result in withdrawal of your offer of employment/disciplinary action, suspension or dismissal

Please answer YES or NO to the following questions.  If you answer YES to any question, please give details overleaf. Any information given will be confidential and used to make a DBS + Safeguarding decision.

DECLARATION

I undertake to inform the Head of Service/Director if I am charged with or convicted of a criminal offence or if I am cautioned or summonsed by the Police whilst employed by Octavia, except for parking offences which give rise to a fixed penalty under the Road Traffic Regulation Act 1984 (or any amendment or replacement thereof) e.g. parking tickets.  I understand that if I do not disclose this information it could result in disciplinary action or dismissal. If the job in which I am employed involves working with children/vulnerable adults, then I confirm that I am not disqualified from working with children and/or vulnerable adults, on any Barred List, or subject to sanctions imposed by any regulatory body e.g. Health and Care Professions Council, The National College of Teaching and Leadership or any other relevant professional body