Self-declaration form
Revised April 2018
Private and Confidential
Self-declaration form for roles involving contact with adults at risk
(Organisation name)is committed to safeguarding adults at risk taking part in its activities from physical, sexual, psychological, emotional or financial harm or neglect. As part of our Safeguarding policy, we require applicants for posts involving contact with adults at risk to complete this self-declaration form.
If your role will involve regular or frequent contact with or responsibility for adults at risk you may also be required to provide a valid Enhanced Criminal Records Disclosure, with Barred List check if relevant (Scotland: to be a member of the Protecting Vulnerable Groups Scheme). Having a criminal record will not necessarily bar you from working with us. This will depend on the nature of the position and the circumstances and background of your offences.
All information will be treated as confidential and managed in accordance with our Data Privacy Policy and current data protection legislation and guidance.
Name …………………………………………………………………………………………..
- Have you ever been known to any Adult Services Department as being an actual or potential risk to adults at risk?
YES / NO
If yes, please supply details.
- Have you ever been the subject of any disciplinary investigation and/or sanction by any organisation due to concerns about your behaviour towards adults at risk?
YES / NO
If yes, please supply details.
Declaration
I declare that to the best of my knowledge the information given above is correct and understand that any misleading statements or deliberate omission may be sufficient grounds for disciplinary action and/or the withdrawal of my appointment.
If required I agree to provide a valid Criminal Records Disclosure (Scotland: PVG Scheme Membership certificate).
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 adults at risk.
I understand that the information contained in this form and in the Disclosure, or supplied by third parties, may be shared with other persons or organisations in circumstances where this is considered necessary to safeguard adults at risk.
Signed: ………………………………………………………….. Date:……………………………
Note: if the applicant is aged under 18, this form should be counter-signed by a parent or guardian