BeSpace Self Disclosure Form

Self Disclosure Form

For roles involving regulated work/activity or requiring standard or enhanced disclosure checks
You are being asked to complete this form because the role you are applying for is exempt from the Rehabilitation of Offenders Act 1974 in England, Scotland and Wales, or the Rehabilitation of Offenders (Northern Ireland) Order 1978 and involves contact with children or young people.

As the role you have applied for involves work with children, you will also be required to undergo the relevant vetting and barring checks.

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.
Name*

First NameLast Name
Previous Name (if applicable)

First NameLast Name
E-mail*
example@example.com
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityCounty

Postcode
Date of Birth*

DayMonthYear
Date
Criminal record declaration.

The role is exempt from the Rehabilitation of Offenders Act 1974 in England, Scotland and Wales or the Rehabilitation of Offenders (Northern Ireland) Order 1978. You are therefore required to declare all unspent convictions and conditional cautions and all spent convictions and adult cautions that are not protected (i.e. eligible to be filtered).
Do you have any unspent conditional cautions or convictions in the UK or overseas?*
If yes, please provide further information:
Do you have any spent adult cautions (simple or conditional) or convictions in the UK or overseas that are not protected (i.e. eligible to be filtered) as defined by the Rehabilitation of Offenders Act 1974 in England, Scotland and Wales or the Rehabilitation of Offenders (Northern Ireland) Order 1978?*
If yes, please provide further information:
Barred List Declaration.

If this role has been defined as regulated activity or work it will also be subject to an enhanced with barred list check in England, Northern Ireland and Wales or checks under the Protecting Vulnerable Groups scheme in Scotland.

It is a criminal offence to apply for or accept a position working with children if you have been barred from/listed as unsuitable to engage in regulated activity/work with children.
Are you included on the list of people barred from/listed as unsuitable to engage in regulated activity/work with children?*
If yes, please provide further information:
If you are not currently barred from working with children, have you been referred to the Disclosure and Baring Service (DBS) or Disclosure Scotland for consideration to be added to one of the lists?*
If yes, please provide further information:
Conduct Declaration.
Have you ever been known to any children’s services department or police as being a risk or potential risk to children?*
If yes, please provide further information:
Have you ever been dismissed for misconduct from any paid or voluntary position previously held by you?*
If yes, please provide further information:
Have you ever been under investigation for or subject to any disciplinary sanctions in relation to your conduct at the time of your employment?*
If yes, please provide further information:
Have you ever been subject to any sanctions being placed on your professional registration, by a regulatory or licencing body in any country? (as applicable) Sanctions may include: Warnings, conditions, limitations, suspensions removal or any other restrictions that may have applied to your professional registration.*
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.*

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.*

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.*

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.*

Agree
By signing below, I confirm that the information I have provided on this form (or attached) is accurate. I understand that this information will not necessarily prevent me from being employed or appointed in the role above, and that I will be given an opportunity to discuss any concerns you might have before you make a final decision on my suitability for the role.
Print Name*
Signature*

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Date*

DayMonthYear
Date
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