Staff Disqualification Declaration Name: Post: Please circle one option for every question Section 1 Orders or other restrictions – Have any orders or other determinations related to childcare been made in YES / NO respect of you? Have any orders or other determinations related to childcare been made in YES / NO respect of a child in your care? Have any orders or other determinations been made which prevents you from YES / NO being registered in relation to child care, children’s homes or fostering? Are there any other relevant orders, restrictions or prohibitions in respect of you YES / NO as set out in the Schedule 1 of the Regulations? Available via the link below: Are you barred from working with Children (Disclosure and Barring (DBS))? YES / NO Are you prohibited from Teaching? YES / NO Section 2 Specified and Statutory Offences – Have you ever been cautioned, reprimanded, given a warning for or convicted of: Any offence against or involving a child? (A child is a person under the age YES / NO of 18)? Any violent or sexual offence against an adult? YES / NO Any offence under the Sexual Offences Act? YES / NO Any other relevant offence? Available from via the links below: YES / NO Have you ever been cautioned, reprimanded, given a warning for or convicted of YES / NO any similar offence in another country? Section 3 Disqualification by association – To the best of your knowledge, is anyone in your household* disqualified from working with children under the Regulations? YES / NO *household includes family, lodgers, house-sharers, household employees –
Staff Disqualification Declaration Name: Post: Please circle one option for every question Section 1 – Orders or other restrictions Have any orders or other determinations related to childcare been made in respect of you? YES / NO Have any orders or other determinations related to childcare been made in respect of a child in your care? YES / NO Have any orders or other determinations been made which prevents you from being registered in relation to child care, children’s homes or fostering? YES / NO Are there any other relevant orders, restrictions or prohibitions in respect of you as set out in the Schedule 1 of the Regulations? Available via the link below: YES / NO Are you barred from working with Children (Disclosure and Barring (DBS))? YES / NO Are you prohibited from Teaching? YES / NO Section 2 – Specified and Statutory Offences Have you ever been cautioned, reprimanded, given a warning for or convicted of: Any offence against or involving a child? (A child is a person under the age of 18)? YES / NO Any violent or sexual offence against an adult? YES / NO Any offence under the Sexual Offences Act? YES / NO Any other relevant offence? Available from via the links below: YES / NO Have you ever been cautioned, reprimanded, given a warning for or convicted of any similar offence in another country? YES / NO Section 3 – Disqualification by association To the best of your knowledge, is anyone in your household* disqualified from working with children under the Regulations? *household – includes family, lodgers, house-sharers, household employees YES / NO
Staff-Disqualification-Declaration.docx