Confidential Declaration Form 

To be completed by those wishing to work with children or vulnerable adults. [This is a very wordy form but actually very straightforward to complete. Won't take much more than a minute. Answering "Yes" to any of the questions does not automatically bar you from being on team - Peter]

The Confidential Declaration Form applies to all adult volunteers who are likely to be in regular contact with children or vulnerable adults. This form is strictly confidential and, except under compulsion of law, will be seen only by those responsible for the appointment and, when appropriate, the Diocesan Safeguarding Adviser or someone in a similar position. All forms will be kept securely under the terms of the Data Protection Act 1998.

If you answer yes to any question, please give details in the space at the bottom of the page, giving the number of the question you are answering. (The Disclosure of an offence may not necessarily prohibit employment.)

1. Have you ever been convicted of a criminal offence (including any spent convictions under the Rehabilitation of Offenders Act 1974)? 
Note: Declare all convictions, cautions, warnings or reprimands 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 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.


2. Have you ever been cautioned by the police, given a reprimand or warning or bound over to keep the peace? 
 
3. Are you at present under investigation by the police or an employer for any offence? 
 
4. Has your name ever been placed on the Protection of Children Act (POCA), List 99, the Protection of Vulnerable Adults List (POVA) or the barred lists maintained by the Independent Safeguarding Authority, barring you from work with children or vulnerable people? 
 
5. Has a family court ever made a finding of fact in relation to you, that you have caused significant harm* to a child or vulnerable adult, or has any such court made an order against you on the basis of any finding or allegation that any child or vulnerable adult was at risk of significant harm* from you? 
 
6. Has your conduct ever caused or been likely to cause significant harm to a child or vulnerable adult, or put a child or vulnerable adult at risk of significant harm*? 
 
7. To your knowledge, has it ever been alleged that your conduct has resulted in any of those things? 
If yes, please give details, including the date(s) and nature of the conduct, or alleged conduct, and whether you were dismissed, disciplined, moved to other work or resigned from any paid or voluntary work as a result.
Note: 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 investigated by the police, Children’s Services, an employer or voluntary body must be declared. Checks will be made with the relevant authorities.


8. 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 child protection planning, a care order, a supervision order, a child assessment order or an emergency protection order under the Children Act 1989, or a similar order under other legislation? 
 

* Significant harm involves serious ill-treatment of any kind including neglect, physical, emotional or sexual abuse, or impairment of physical or mental health development. It will also include matters such as a sexual relationship with a young person or adult for whom you had pastoral responsibility or were in a position of trust.

If you have answered YES to any of the previous questions then please provide further details in the space below.  

Declaration and Undertaking

I declare that the above information is accurate and complete to the best of my knowledge.

 

I undertake to inform the relevant church authorities promptly should any convictions, court orders or allegations concerning matters of this kind arise.

Your name & surname: 
 
Do you possess a current (i.e. less than 3 years old) DBS ceritificate? 

Press SEND (below) to submit your answers.  And, if you are not an active member of St Matthew's or All Saints' first give the contact details of someone who could provide a reference (church minister, employer, tutor, voluntary sector leader):
Reference Name:
Relationship to you:
How long have they known you:
Email:
Phone number:
 
Peter Shields, 22/05/2015