Model Declaration form A: positions which are exempt from the ROA (revised October 2016)

MODEL DECLARATION FORM A

When Barnet, Enfield and Haringey Mental Health NHS Trust is assessing your character and
suitability for any such appointment, it is legally permitted to ask for and consider any information
relating to unspent (current) and spent (old) criminal convictions, police cautions, final warnings or
reprimands which are not protected (or filtered out) by the Rehabilitation of Offenders Act 1974
(Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013.

You are not legally obliged to declare any convictions or cautions which are protected under the
Exceptions Order. Employers must not ask for, or consider any such information as part of their
recruitment process. Before completing this form it will be important for you to read the useful
guidance section on page two which provides additional advice about the type of criminal history
information you must declare.

Where relevant to the role, the organisation may also ask you to provide any information about any
investigations and/or formal action taken against you by a regulatory or licencing body which may
have had an impact on your professional registration and/or fitness to practise in your chosen
profession.

Any information you declare when completing this form will be verified by undertaking a follow-up
check with the relevant body. It will also include carrying out a standard or enhanced disclosure
through the Disclosure and Barring Services (known as a DBS check).

Enhanced disclosures may also include other non-conviction information which may be held on
central police databases, where this is regarded as relevant to the position you are applying for. If
the position has, in addition, been identified as a ‘regulated activity’ under the Safeguarding
Vulnerable Groups Act 2006 (as amended by the Protection of Freedom’s Act 2012), the enhanced
disclosure will also include any information that may be held about you on the children’s and/or
adults barred list(s).

Our fair recruitment promise

Barnet, Enfield and Haringey Mental Health NHS Trust aims to promote equality of opportunity and
is committed to treating all applicants for positions fairly and on merit regardless of ethnicity,
disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or
maternity, marriage or civil partnership.

The organisation does not discriminate unfairly against applicants on the basis of criminal
conviction or other such information declared. If we believe that the information you have declared
is relevant to the position you are applying for, we will discuss this with you prior to making our final
recruitment decision. If information is not raised with you, this is because we do not believe that
this should be taken into account. In any event, you remain free to discuss the matter with the
recruiting manager or human resources department should you wish to do so.

All information will be examined on a case-by-case basis alongside the full range of information we
gain about you as part of our recruitment process. It is important to stress that answering yes to
any of the questions in the attached form does not mean that you will be prevented from taking up
an appointment in the NHS.
 Model Declaration form A: positions which are exempt from the ROA (revised October 2016)

How will my information be used?

The information that you provide in this declaration form will be processed in accordance with the
Data Protection Act 1998. It will only be used for the purpose of determining your application for
this position. It will also be used for purposes of enquiries in relation to the prevention and
detection of fraud.

If you have declared any information relating to criminal convictions or other such offences, we will
consider the following:

 The relevancy of the conviction/offence to the position being applied for.

It is important to be aware, that the failure to disclose all spent and unspent convictions which you
are legally obliged to declare (i.e. those that are not protected by Exceptions Order of the
Rehabilitation of Offenders Act (as amended in England and Wales), could result in disciplinary
proceedings or dismissal.

Please ensure that you take the time to read the supplementary guidance that we sent to you with
your application form. This provides you with detailed information about how we will process your
application, the persons to whom information will be disclosed, and the range of checks that we will
undertake as part of our recruitment process.

Useful guidance

If you have a criminal history, it will be important for you to refer to the easy to read guidance
documents provided on the Unlock website.

Unlock is a charity body that provides information and advice to individuals to help them gain a
greater understanding about the type of information employers are likely to seek about their
criminal history, which convictions and cautions are protected under the Exceptions Order (i.e. will
never be disclosed as part of a DBS check and do not need to be declared when completing this
form) and their rights.
 Model Declaration form A: positions which are exempt from the ROA (revised October 2016)

MODEL DECLARATION FORM A

Please complete and return the form only to: The Recruitment Team at Barnet, Enfield and
Haringey Mental Health NHS Trust

Before completing this form, it is important to note the following points:

1. You must answer all the questions in this form.

2. Before ticking yes or no, please ensure that you to read the explanatory notes which are
provided underneath each of the questions. These notes are intended to guide you in
determining what additional information you will be required to provide to support your
answers.

3. If you answer yes to any of the questions, please use the space provided to include any
relevant information about your suitability for the position you are applying for.

4. If you would like any additional supplementary evidence to support your application to be
considered, please ensure it is attached or uploaded with this form when you return it.

5. You are not required to disclose information about parking offences.

Applicant details
Full name (in Pauline Gordon Contact details 07957 151999
block capitals)
Role applied for Health Care Assistant

1. Are you currently bound over, or have you ever been convicted of any offence by a Court No
or Court-Martial in the United Kingdom or in any other country?

You should tick no, if any convictions are protected (or filtered out) by the Rehabilitation of
Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) 2013. Please
refer to information about protected convictions and cautions in the useful guidance section.

If you have ticked yes, please provide details of the order binding you over and/or the nature of the
offence, penalty, sentence or order of the Court, the date and place of the Court hearing.

2. Have you ever received a police caution, reprimand or final warning in the United Kingdom No
or in any other country?

You should tick no, if any cautions, reprimands or final warnings are protected (or filtered out)
by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England
and Wales) 2013. Please refer to further information about protected convictions and cautions in
the useful guidance section.

If you have ticked yes, please provide details of the caution, reprimand or final warning, including the date
and reason administered.
 Model Declaration form A: positions which are exempt from the ROA (revised October 2016)

3. Have you been charged with any offence in the United Kingdom or in any other country that No
has not yet been disposed of?

Please note that you must inform us immediately if you are charged with any offence in the
United Kingdom or in any other country after you complete this form and before taking up any
position offered to you.

If you have ticked yes, please provide details of the nature of the offence with which you are charged, date
on which you were charged, and details of any on-going proceedings by a prosecuting body.

4. Are you aware of any current investigations being undertaken by the police following No
allegations being made against you in the United Kingdom or in any other country?

If you have ticked yes, please provide details of the nature of the allegations made against you and, if known
to you, any action to be taken against you by the police.

Please note that we will only take into account any current investigations which might be relevant to the
position you are applying for.

5. Have you ever been investigated by the NHS Business Services Authority (formerly NHS No
Counter Fraud and Security Management Services) or any other investigatory body
resulting in a current or past conviction or any formal action being taken against you?

If you have ticked yes, please provide details of the offence, including any dates.

Investigatory bodies may include:

HM Revenue & Customs, the Financial Services Authority, Department for Business, Energy and Industrial
Strategy (formerly the Department of Trade & Industry), Department of Work and Pensions, Home Office,
UK Visas and Immigration and local authorities.

This list is intended as a guide only, you must declare any investigation conducted by an investigatory body.

6. Have you ever been dismissed by reason of misconduct from any employment, No
volunteering, office, or other position previously held by you?

If you have ticked yes, please provide details of the employment, volunteering, office, or other position held,
the date that you were dismissed and the nature of allegations of misconduct made against you.
 Model Declaration form A: positions which are exempt from the ROA (revised October 2016)

7. Are you currently subject to a fitness to practise investigation and/or proceedings of any No
nature by a regulatory or licensing body in the UK or in any other country?

If you have ticked yes, please provide the reasons given for the investigation and, where applicable, the details
of any warnings, conditions or sanctions (including limitations, suspension or any other restrictions) that apply to
your professional registration and, the name and address of the regulatory or licensing body concerned.

Please note that we will only take into account any current fitness to practise investigation or proceedings
which might be relevant to the position you are applying for.

8. Have you ever been removed from the register, or have conditions or sanctions been No
placed on your registration, or have you been issued with a warning by a regulatory
or licensing body in the UK or in any other country?

You should tick no, where any right to appeal has been upheld and where that appeal
has resulted in your case being fully exonerated.

If you have ticked yes, please provide details of any conditions or sanctions (including limitations, suspension
or any other restrictions) that apply to your registration and/or any warnings issued, where relevant and, the
name and address of the regulatory or licensing body concerned.

9. Are you subject to any other prohibition, limitation, or restriction that means we are/or may No
be unable to consider you for the position for which you are applying?

If you have ticked yes, please include details of the nature of the prohibition, restriction or limitation and by
whom it was made.
 Model Declaration form A: positions which are exempt from the ROA (revised October 2016)

Continuation sheet:

If you have answered yes to any of the questions above, please use the space below to provide any additional
information you wish us to consider as part of your application. You may continue on a separate sheet or
attach any additional evidence, if you wish to do so.

Please clearly indicate the number of the question to which the information relates.
 Model Declaration form A: positions which are exempt from the ROA (revised October 2016)

Declaration
IMPORTANT

The Data Protection Act 1998 requires us to advise you that we will be processing your personal data.
Processing includes: holding, obtaining, recording, using, sharing and deleting information.

The Act defines ‘sensitive personal data’ as racial or ethnic origin, political opinions, religious or other beliefs,
trade union membership, physical or mental health, sexual life, criminal offences, criminal convictions,
criminal proceedings, disposal or sentence.

The information that you provide in this declaration form will be processed in accordance with the Data
Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also
be used for purposes of enquiries in relation to the prevention and detection of fraud.

Once a decision has been made concerning your appointment, Barnet, Enfield and Haringey Mental Health NHS
Trust will not retain this declaration form any longer than is necessary - see further details in the supplementary
guidance notes for applicants which we provided with your application form. This declaration will be kept
securely and in confidence. Access to this information will be restricted to designated persons within the
organisation who are authorised to view it as a necessary part of their work.

In signing the declaration on this form, you are explicitly consenting for the data you provide to
be processed in the manner described above.

I confirm that the information that I have provided in this declaration form is correct and complete. I understand
and accept that if I knowingly withhold information, or provide false or misleading information, this may result
in my application being rejected, or if I am appointed, in my dismissal, and I may be liable to prosecution.

Please sign and date this form.

Full name (in PAULINE GORDON Signature Pauline Gordon

Date 22/10/2020

If you need any assistance or advice before returning this form to us, or you wish to withdraw your consent
at any time after you have submitted this form, please contact your Recruitment Advisor at Barnet, Enfield
and Haringey Mental Health NHS Trust

All enquiries will be treated in strict confidence.