DECLARATION FORM

Guidance for applicants (please read fully before completing the attached form)
When assessing your suitability for NHS appointments Chelsea & Westminster NHS Hospital Trust is
required to ask for certain information as part of our recruitment process, in accordance with the NHS
Employment Check Standards.

These standards outline a range of checks that organisations in England must undertake when appointing
to NHS positions. This includes information about criminal records and/or registration with any professional
regulatory or licensing body (including investigations or formal action in relation to fitness to practise) as
may be applicable to the role. It also includes obtaining employment history and/or other references which
may provide information about any relevant conduct and/or behaviour that might need to be considered as
part of our overall assessment of an applicant’s suitability for the position in question.

Asking applicants to complete a self-declaration enables us to have an open discussion, should we need
to, to gain a better understanding about the circumstances surrounding any information disclosed. It also
provides applicants with the chance to present any additional evidence they may wish us to consider in
support of their application, and/or to ask questions, if anything is unclear. Should additional information be
required, we will contact you to arrange a mutually convenient time to have a face to face meeting or
discussion over the telephone.

Under normal circumstances, we will only ask successful applicants to complete model declaration form A
once a conditional offer of appointment has been issued. We may require applicants to complete this form
earlier in the recruitment process, where there is a safeguarding requirement for us to recruit quickly (for
instance, to allow us to mitigate risks to patient services or care). Any requirements for you to complete this
form earlier in the recruitment process will have been made clear to you when you first applied for this
position.

Once we have received your completed form, we may be required to carry out a follow-up check with any
relevant bodies such as the Disclosure and Barring Service (DBS), professional regulatory or licensing
bodies, as may be appropriate to the role being applied for, and, in accordance with the NHS Employment
Check Standards.

IMPORTANT INFORMATION:
The role you have applied for is exempt from the provisions normally afforded to individuals under the
Rehabilitation of Offenders Act 1974. This means that we are required to obtain a standard or enhanced
disclosure through the Disclosure and Barring Service (known as a DBS check) as defined under the
Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended). It also means that you need
to carefully consider the type of information you will need to declare when answering questions 1-4 in
Model declaration form A (attached).

Before answering questions 1-4 you must ensure you read and understand the section about disclosing
information about criminal record history below, which explains what information is required and signposts
you to where you can seek free confidential and independent advice, if you are unsure.

Fair recruitment promise

It is important for us to stipulate that answering YES to any of the questions in the attached form does not
mean an automatic bar to being considered for a position in the NHS.
Model declaration form A: To be used for positions which are in addition exempt from the Rehabilitation of Offenders
Act (i.e. are eligible for a standard or enhanced DBS check) (revised July 2019)

Chelsea & Westminster NHS Hospital Trust is committed to treating all applicants equally and fairly
based on their skills, experience and ability to fulfil the duties of the role being applied for. This is
regardless of ethnicity,

disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or
maternity, marriage or civil partnership.

Suitable applicants will also not be refused positions because of criminal record information or other
information declared, where it has no bearing on the role for which you are applying, and/or no risks have
been identified against the duties you would be expected to perform as part of this role. The only exception
to this rule is where there is a legal or regulatory reason which would prevent you from working or
volunteering in certain positions. For instance, individuals who appear on the adults and/or children’s
barred list(s) managed by the Disclosure and Barring Service (DBS) would be committing a criminal offence
if they apply for a regulated activity from which they are barred from working or volunteering in. In such
circumstances, it would also be illegal for an employer to allow that individual to engage in a regulated
activity from which they are barred.

Failure to provide accurate and truthful information is considered a serious matter. If, as part of our
checking process, it becomes apparent that an applicant has provided us with inaccurate information or
they have not provided relevant information, we will need to discuss this with them to establish why. Any
finding of serious misdirection or deliberate intent to deceive will result in their application being disqualified
or disciplinary action and/or dismissal, if they are already in post.

If you have any questions or would like further advice about what information we might require as part of
our recruitment process, please feel free to contact the medical recruitment team. All queries will be dealt
with in strict confidence.

Disclosing criminal record information

When completing questions 1-4 in Model declaration form A (attached), you will need to declare all
convictions that are not protected (i.e. eligible for filtering) as defined by the Rehabilitation of Offenders
Act 1974 (Exceptions) Order 1975 (as amended).

In April 2013, youth cautions and youth conditional cautions were introduced by the Legal Aid, Sentencing
and Punishment of Offenders Act 2012 (LASPO) to replace reprimands and final warnings. When
completing this form, you will also need to declare all cautions and/or reprimands and final warnings which
are not protected.

This includes any cautions and/or reprimands and final warnings that may have been issued in another
country, where an equivalent offence in England and Wales is not protected.

Convictions, cautions, reprimands and final warnings must be declared regardless as to whether they are
spent or are still considered unspent. This requirement applies to certain NHS positions which involve high
levels of contact with children and adults who are receiving or accessing health and care services.

If the position is eligible for an enhanced disclosure, any subsequent check we carry out with the
Disclosure and Barring Service (known as a DBS check) may include other relevant non-conviction
information held on police databases, at the discretion of the Chief Constable of the relevant police force.

If the position you are applying for is a regulated activity as defined under the Safeguarding Vulnerable
Groups Act 2006 (amended by the Protection of Freedoms Act in 2012), the enhanced disclosure may also
include any information that is held about you on the children’s and/or adults barred list(s). As outlined in
Model declaration form A: To be used for positions which are in addition exempt from the Rehabilitation of Offenders
Act (i.e. are eligible for a standard or enhanced DBS check) (revised July 2019)

the section above, applicants must not apply for or engage in a regulated activity that they are barred from
working or volunteering with.

Any criminal record information disclosed will be considered on a case-by-case basis. We will only take into
account information that is relevant to the position for which you are applying. This information will be
balanced against the skills and competencies you have demonstrated throughout the recruitment process
alongside other information we have obtained about you as part of our pre-employment check process.

If you declare information that is relevant to the role for which you are applying, we will also take into
account:

 the seriousness of the offence(s)

 your age when you committed the offence(s)
 the length of time since the offence(s) occurred
 if there is a repeated or pattern of offending behaviour
 the circumstances surrounding the offence(s)
 any evidence you provide to demonstrate that your circumstances have changed since the
offending behaviour.

This mirrors the Code of Practice issued by the Disclosure and Barring Service (DBS). Although the Code
outlines what needs to be considered when criminal record information is disclosed as part of a DBS check,
the NHS Employment Check Standards require employers to take the same approach when considering
criminal record information that might be self-declared by applicants using model declaration form A
(attached).

We appreciate that the criminal record disclosure regime is complex and difficult to understand, it is
therefore essential for us to signpost applicants to where they can seek further information and advice
about what may be included on their criminal record (if they have one), what they need to declare to any
organisation they may be working or volunteering with, and their legal rights when doing so.

The following charities are experts in this field, offering free, independent and confidential advice to
individuals who have a criminal record:

 Nacro – Tel: 0300 123 1999, or email: [email protected]

 Unlock – Tel: 01634 247350 (Mon-Fri 10am – 4pm), Text or WhatsApp: 07824 113848, email
[email protected] or complete the online form on the Unlock website.

How will my information be used?

The information you provide using model declaration form A (attached) will be used for determining your
suitability for the position you have applied for, and in accordance with the NHS Employment Check
Standards. It will also be used for enquiries in relation to the prevention and detection of fraud.

Under the Data Protection Act 2018 and the General Data Protection Regulation 2018 (GDPR)
organisations must provide you with detailed information which explains why certain information is required
as part of the recruitment process, the lawful basis for collecting it, how it will be processed, and with whom
information will be shared and under what circumstances. Please ensure that you read the
supplementary guidance we provided when you first applied for this role as this explains how we may
process your data and your rights under data protection laws.
Model declaration form A: To be used for positions which are in addition exempt from the Rehabilitation of Offenders
Act (i.e. are eligible for a standard or enhanced DBS check) (revised July 2019)

How will information be retained and for how long?

Once a recruitment (or other relevant) decision has been made, we will not keep any information declared
in model declaration form A for any longer than is necessary. As a minimum this should be for a period of
six months to allow for considerations and resolution of any disputes or complaints. There may be
circumstances where we are required to retain information for longer i.e. for the purpose of demonstrating
safe recruitment practice as part of any scheduled safeguarding audits.

Information will be held in accordance with the Data Protection Act, General Data Protection Regulation
(GDPR) and the Human Rights Act. The form and any supplementary information provided by applicants
with this form, will be kept securely and separately from any personnel records and access will be strictly
limited to those who are entitled to see it as part of their duties, as outlined within our local policy on the
correct handling and safekeeping of special categories of personal data.

Once the retention period has elapsed, we will ensure that any information provided is destroyed by secure
means, for example by shredding, pulping or burning. While awaiting destruction, the secure handling of
information, as outlined above, will be adhered to. While the form and any supplementary information
applicant’s chose to provide will be destroyed, we will need to keep a record of the date of when a self-
declaration was requested/received, the position for which the self-declaration was requested, and the
details of the recruitment decision taken.
Model declaration form A: To be used for positions which are in addition exempt from the Rehabilitation of Offenders
Act (i.e. are eligible for a standard or enhanced DBS check) (revised July 2019)

DECLARATION FORM
Please complete and return the form only by replying to the e-mail received from Trac systems.

Before completing this form, it is important for you to note the following points.

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

2. Before ticking “yes” or “no” please ensure you read the explanatory notes underneath each question.
These notes outline what information you should consider providing to support your answer.

3. If you answer “yes” to any of the questions, please use the space provided to include any information that
may be relevant to the position for which you are applying.

4. If you would like to submit any additional supplementary evidence for us to consider in support of your
application, please attach or upload this with the form when you return it to us.

5. When answering questions 1-4 you are not required to disclose information about parking offences.

6. You should notify us, at the earliest opportunity, if any information provided in this form subsequently
changes once you have submitted it to us and before taking up the appointment.

Applicant details
Full name (in block capitals) Contact telephone no:

Role applied for Contact email address:

1. Do you have any convictions that are not protected (i.e. eligible for filtering) as outlined Yes No
in the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended) (the
Exceptions Order)?

It also includes all convictions or Summary Hearings that have been issued under military law while
serving in the Armed Forces, either in the UK or any other country, where the equivalent offence in
England and Wales is not protected.

You are not required to disclose any information in relation to the above if ALL convictions are
protected (i.e. eligible for filtering) as outlined in the Exceptions Order. In these circumstances
you should tick NO to this question.

This requirement is regardless as to whether any conviction is spent or remains unspent.

Please ensure that you read guidance in the section on disclosing criminal history
information before completing this question.

If you have ticked YES, you now have two options on how to disclose this information.

Option 1: Please provide details of the conviction or Summary Hearing, including the date and reason
administered in the space below.
Model declaration form A: To be used for positions which are in addition exempt from the Rehabilitation of Offenders
Act (i.e. are eligible for a standard or enhanced DBS check) (revised July 2019)

Option 2: You can disclose your record separately together with any statement detailing your conviction or
Summary Hearing. Any supplementary information should be marked CONFIDENTIAL and state your full name
and details of the position being applied for.

To do this you must mark an “X” against the statement below.

I have attached details of my conviction separately …… (please mark with an “X”)

2. Do you have any cautions, reprimands or final warnings that are not protected (i.e. eligible for filtering)
as outlined in the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended) (the
Exceptions Order)?

It also includes all cautions, reprimands or final warnings that have been issued under military law while serving in the
Armed Forces, either in the UK or any other country, where the equivalent offence in England and Wales is not
protected.

You are not required to disclose any information in relation to the above if ALL convictions are protected (i.e.
eligible for filtering) as outlined in the Exceptions Order. In these circumstances you should tick NO to this
question.

This requirement is regardless as to whether any caution, reprimand or final warning is spent or remains
unspent.

Please ensure that you read guidance in the section on disclosing criminal history information before
completing this question.

If you have ticked YES, you now have two options on how to disclose this information.

Option 1: Please provide details of the caution, reprimand or final warning, including the date and reason
administered in the space below.

Option 2: You can disclose your record separately together with any statement detailing your caution,
reprimand, or final warning. Any supplementary information should be marked CONFIDENTIAL and state your
full name and details of the position being applied for.

To do this you must mark an “X” against the statement below.

I have attached details of my conviction separately …… (please mark with an “X”)

3. Have you been formally charged with any other offence which has not yet been disposed Yes No
of?

This includes where you have been formally charged of any offence that has been issued in any
other country which has not yet been disposed of.

Please note that you must inform us immediately if you are formally charged with any offence
after you complete this form and before taking up any position offered to you.
Model declaration form A: To be used for positions which are in addition exempt from the Rehabilitation of Offenders
Act (i.e. are eligible for a standard or enhanced DBS check) (revised July 2019)

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

You may use the continuation sheet attached if necessary – please indicate which question information relates
to, if doing so.

4. Are you currently subject to any criminal investigations or pending prosecutions by the Yes No
police which may have a bearing on your suitability for this post?

This may also include any current criminal investigations or pending prosecutions by the police
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.

You may use the continuation sheet attached if necessary – please indicate which question information relates
to, if doing so.

5. Have you ever been subject to any formal action being taken against you by the NHS Yes No
Counter Fraud Authority (formerly NHS Counter Fraud and Security Management
Services) or any other investigatory body in relation to allegations of fraud, which may
have a bearing on your suitability for this post?

Any other investigatory bodies may include: HM Revenue & Customs, Financial Services
Authority, Department for Business, Energy and Industrial Strategy (formerly the Department of
Trade & Industry), Local Authorities, Department of Work and Pensions, Home Office, and UK
Visas and Immigration.

This list is not exhaustive and should be taken as a guide only. You must declare any action
taken against you by an investigatory body, following allegations of fraud.
If you have ticked YES, please provide details of the offence, formal action taken, dates and investigatory or
prosecuting body, as may be relevant.

You may use the continuation sheet attached if necessary – please indicate which question information relates
to, if doing so.
Model declaration form A: To be used for positions which are in addition exempt from the Rehabilitation of Offenders
Act (i.e. are eligible for a standard or enhanced DBS check) (revised July 2019)

6. Have you ever been dismissed for misconduct from any employment, volunteering, office, Yes No
or other position previously held by you, in circumstances which may have a bearing on
your suitability for this post?
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.

You may use the continuation sheet attached if necessary – please indicate which question information relates
to, if doing so.

7. Are you currently subject to a fitness to practise investigation and/or proceedings of any Yes No
nature by a regulatory or licensing body, which may have a bearing on your suitability for
the position you are applying for?

This may include any fitness to practise investigation and/or proceedings of any nature that are
being undertaken by a regulatory or licensing body 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.

You may use the continuation sheet attached if necessary – please indicate which question information relates
to, if doing so.

8. Have you ever been removed from the register, or have conditions or sanctions been Yes 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 are not required to disclose any information in relation to the above where any right to
appeal has been upheld and where that appeal has resulted in your case being fully exonerated.
In these circumstances you should tick NO to this question.
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.

You may use the continuation sheet attached if necessary – please indicate which question information relates
to, if doing so.

Declaration
IMPORTANT INFORMATION
The Data Protection Act 2018 and General Data Protection Regulation 2018 (GDPR) requires us to provide you
with detailed information which explains the lawful basis for collecting special categories of personal data
(previously known as sensitive personal data), how it will be processed, who information will be shared with and
under what circumstances.
Model declaration form A: To be used for positions which are in addition exempt from the Rehabilitation of Offenders
Act (i.e. are eligible for a standard or enhanced DBS check) (revised July 2019)

The General Data Protection Regulation defines special categories of personal data as racial or ethnic original,
political opinions, religious or philosophical beliefs, trade union membership, genetic data, biometric data, data
concerning health or data concerning a natural person’s sex life or sexual orientation. It also includes data relating
to criminal convictions, criminal offences or related security measures. It is important that you read the
supplementary guidance we provided at the time of your application, which explains our policy on the retention
and erasure of any such information in greater detail. This information also outlines your rights under the data
protection and human rights laws.

The information you provide using model declaration form A will be processed in accordance with data protection
law, as described above. It will used for the purpose of determining your suitability for the position you have
applied for, in accordance with the NHS Employment Check Standards. It will also be used for enquiries in relation
to the prevention and detection of fraud.

Once a recruitment (or other relevant) decision has been made Chelsea & Westminster NHS Hospital
Trust will not keep any information declared in this form for any longer than is necessary. As a minimum this will
be for a period of six months to allow for considerations and resolution of any disputes or complaints. There may
be circumstances where we are required to retain information for longer i.e. for the purpose of demonstrating safe
recruitment practice as part of any scheduled safeguarding audits.

The form and any supplementary information provided by applicants with this form, will be kept securely and
separately from any personnel records and access will be strictly limited to those who are entitled to see it as part
of their duties, as outlined within our local policy on the correct handling and safekeeping of special categories of
personal data.

Once the retention period has elapsed, we will ensure that any information provided is destroyed by secure
means, for example by shredding, pulping or burning. While awaiting destruction, the secure handling of
information, as outlined above, will be adhered to.

While the form and any supplementary information applicant’s chose to provide will be destroyed, a record will be
retained of the date of when a self-declaration was requested/received, the position for which the self-declaration
was requested, and the details of the recruitment decision taken.

Please sign and date this form as indicated below

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 the medical recruitment coordinator/advisor.

All enquiries will be treated in strict confidence.

In signing this form, you are agreeing to the following statements:

1. I confirm that I have read and understood guidance provided to me which explains how my data will be
processed and give my consent for enquiries to be made, as outlined.

2. I declare that the information I have provided in this form and in any accompanying documentation, is true to
the best of my knowledge and belief.

3. I understand and accept that if I knowingly withhold relevant information or provide false or misleading
information, this may result in my application being rejected; or, if I am appointed, my dismissal; and, where
applicable, this may result in the employing organisation making a referral to any relevant regulatory or
licensing body.

4. I agree to notify the employing organisation of any subsequent change to the information supplied in this form
before I take up appointment.

Full name (in block capitals) Signature

Date
Model declaration form A: To be used for positions which are in addition exempt from the Rehabilitation of Offenders
Act (i.e. are eligible for a standard or enhanced DBS check) (revised July 2019)

Continuation sheet:
Full name: Position applied for:

If you have ticked YES to any of the questions above, please use the space below to provide any additional
information you may wish us to consider in support of your application.

Please clearly indicate the number of the question to which the information relates. You can continue on a
separate sheet or attach other pieces of evidence to this form, if you wish to do so.