SERVICE *Position applied for ………………………………………………………………………………………….. Brief description of job role ……………………………………………………………………………………………. *Organisation name ………………………………………………………………………………………….. ☐ ☐ *Will the work be carried out at the home of the applicant? YES NO ☐ ☐ *Is the disclosure required for the purposes of asking an exempted question? YES NO ☐ ☐ *Is the disclosure required for a prescribed purpose? YES NO ☐ ☐ *Does this person require a check of the Children’s Barred list (Regulated Activity)? YES NO *Does this person require a check of the Vulnerable Adults’ Barred List ☐ ☐ (Regulated Activity)? YES NO *I have explained to the applicant the significance of making a ☐ list check application’ should the applicant be on one of the barred Lists YES ‘Barred *I confirm that I have the applicant’s permission to progress with an application ☐ that involves the barred list check YES ☐ ☐ VOLUNTEER check YES NO
SERVICE *Position applied for ………………………………………………………………………………………….. Brief description of job role ……………………………………………………………………………………………. *Organisation name ………………………………………………………………………………………….. *Will the work be carried out at the home of the applicant? YES ☐ NO ☐ *Is the disclosure required for the purposes of asking an exempted question? YES ☐ NO ☐ *Is the disclosure required for a prescribed purpose? YES ☐ NO ☐ *Does this person require a check of the Children’s Barred list (Regulated Activity)? YES ☐ NO ☐ *Does this person require a check of the Vulnerable Adults’ Barred List (Regulated Activity)? YES ☐ NO ☐ *I have explained to the applicant the significance of making a ‘Barred list check application’ should the applicant be on one of the barred Lists YES ☐ *I confirm that I have the applicant’s permission to progress with an application that involves the barred list check YES ☐ VOLUNTEER check YES ☐ NO ☐