Fitness to practice (Please complete if member has been reported to their professional body) Name of registration body Professional registration PIN number Disclosure and Barring scheme Are you barred from working for either the Disclosure and Barring scheme or Disclosure Scotland? Barred adults list YES NO (please tick box) Barred childrens list YES NO (please tick box) Case details (Please use continuation sheet if necessary) Date of incident (or most recent incident) which is the subject of this case Please give as much detail as possible, including dates of any incidents, meetings or conversations, and who was involved. If a meeting or hearing has been arranged please give details below. Please attach copies of any relevant correspondence.
Fitness to practice (Please complete if member has been reported to their professional body) Name of registration body Professional registration PIN number Disclosure and Barring scheme Are you barred from working for either the Disclosure and Barring scheme or Disclosure Scotland? Barred adults list YES NO (please tick box) Barred childrens list YES NO (please tick box) Case details (Please use continuation sheet if necessary) Date of incident (or most recent incident) which is the subject of this case Please give as much detail as possible, including dates of any incidents, meetings or conversations, and who was involved. If a meeting or hearing has been arranged please give details below. Please attach copies of any relevant correspondence.
24628_CaseForm_August2017_WORD.docx