Model declaration form A: To be used for positions which are eligible for a standard or enhanced

DBS check under the Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended)

MODEL DECLARATION FORM A

Guidance for applicants (please read before completing the attached form)
When assessing your suitability for a position in the NHS including subsidiary companys, NTW Solutions Limited is
required to ask for certain information to comply with the NHS Employment Check Standards issued by NHS
Employers. These standards outline the type of background checks NHS organisations in England must obtain as
part of their recruitment process.

Under normal circumstances we only require shortlisted applicants to complete model declaration form A. If there are
safeguarding reasons which require us to obtain information about you earlier in the recruitment process (i.e. to
maintain safe levels of service or patient care), this will have been made clear to you when you first applied for this
position.

Asking applicants to complete a self-declaration has two purposes. Firstly, it helps us to have an open conversation
at interview about the circumstances behind any information you may have declared. If we think this is necessary, we
will let you know when we invite you for interview. Secondly, it gives you an opportunity to present any other evidence
you might like us to consider in support of your application and/or to ask questions, if anything is unclear.

Where relevant to the role you are applying for, we may be required to carry out follow up checks with any
professional bodies, for example any professional regulatory or licensing bodies you may be registered with.

Fair recruitment promise

NTW Solutions Limited is committed to treating all applicants equally and fairly based on their skills, experience and
ability to fulfil the duties required. This is regardless of any protected characteristics (ethnicity, disability, age, gender
or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity, marriage or civil partnership).

Answering YES to any of the questions in the attached form does not mean that you will be excluded from being
considered for an NHS position. The only exception to this rule is where there is a legal reason which would prevent
you working or volunteering in certain roles – see information on disclosing criminal record information below. In all
cases, we will only consider information that is relevant to the position you have applied for and where there may be
associated risks against the duties you may be required to carry out as part of this role.

Failure to provide accurate and truthful information is considered a serious matter. If it becomes apparent that
inaccurate or incomplete information has been provided, we will need to establish why. Any finding of serious
misdirection or intent to deceive will result in an application being disqualified or, if appointed, disciplinary action
being taken and/or dismissal.

If you have any questions about our recruitment process, please feel free to discuss this with us by contacting the
Workforce Team [email protected]. All queries will be treated in strict confidence.

Disclosing criminal record information

The position you have applied for is an ‘exempt position’. This means it is not covered by the provisions in the
Rehabilitation of Offenders Act 1974. When appointing to an exempt position we are legally permitted to obtain a
standard or enhanced check through the Disclosure and Barring Service (known as a DBS check). Any request for
such a check must comply with the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (the Exceptions
Order) and/or the Police Act 1997 (as amended]. For applicants being recruited from overseas there is a requirement
for us to obtain an overseas police certificate or certificate of good conduct. There are other circumstances where this
might also be required, i.e. where a UK citizen has visited any other countries for an extended period of time. We will
explain any such requirements to you if this applies. All overseas certificates are issued in line with the disclosure
rules according to the issuing country.

When answering questions 1-4 in the attached form, you must declare all criminal convictions and/or cautions that
are not protected (i.e. eligible for filtering) under the Exceptions Order (as amended). This is regardless of whether
you have been convicted in the UK or overseas. This includes criminal convictions or relevant service discipline
convictions received within the Armed Forces Justice System (e.g. through Summary Hearing or Court Martial),
where it would be considered an equivalent (or similar) offence in England and Wales.
Model declaration form A: To be used for positions which are eligible for a standard or enhanced
DBS check under the Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended)

If we inform you that the position is eligible for an enhanced disclosure, any follow up DBS check may also include
other relevant information held at the discretion of the Chief Constable of the relevant police force.

If we inform you that the position is a regulated activity as outlined in the Safeguarding Vulnerable Groups Act 2006
(amended in 2012), any enhanced disclosure may also include information that is held about you on the children’s
and/or adults barred list(s). It is important to note that individuals must not apply for/or engage in a regulated activity
that they are barred from working or volunteering in. Any attempt to do so is a criminal offence. As an employer we
would also be committing an offence if we were to knowingly employ someone in a regulated activity from which they
are barred.

We are required by law to make you aware of the relevant pieces of legislation that requires or permits us to ask for
certain information. Understanding what offences might need to be declared to a prospective employer will be critical
to ensure you do not disclose information you are not legally bound to declare or omit relevant information that must
be declared. The requirements under the criminal record disclosure regime are complex and subject to periodic
change. If you are unsure about whether you need to disclose certain criminal record information, free confidential
advice may be sought from one of the charity bodies listed below. These bodies can advise you on what you are
legally required to declare and may also be able to advise you on how you can disclose criminal record information to
a prospective employer and your legal rights when doing so.

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

 Unlock – Tel: 01634 247350, email [email protected] or complete the online form on the Unlock website.

When considering criminal record information, we will take into account:

 information which is relevant to the position being applied for
 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
 any information you can provide to explain the circumstances surrounding the offence(s)
 any information you can provide to demonstrate that your circumstances have changed since the offending
behaviour.

This approach mirrors guidance in the DBS Code of Practice which employers must comply with when considering
disclosure certificate information.

All criminal record information will be carefully considered alongside any skills and competencies you may have
demonstrated during the application and interview stages and/or any evidence you may have presented as part of
our checking process.

Data protection
Under the Data Protection Act 2018, we have a legal duty to provide you with 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 with. Please read the data protection section at the end of the attached
form which describes this in more detail.
Model declaration form A: To be used for positions which are eligible for a standard or enhanced
DBS check under the Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended)

MODEL DECLARATION FORM A

To note before completing this form:
1. You must answer all questions in this form. Please read the notes underneath each question, as these explain
what you need to consider before responding.

2. If answering ‘yes’ to any of the questions, you should use the space provided in the form to include any
supporting information that you would like us to consider.

3. You can provide additional evidence separately. This should be clearly marked with your full name, position
applied for and the number of the question it relates to. Place this in a sealed envelope marked ‘Confidential’
and attach this to your completed model declaration form.

4. If any information you have declared changes after you have returned this form to us, you must let us know at
the earliest opportunity before your commencement date.

Please return your completed form alongside any additional evidence to NTW Solutions Workforce Team at
[email protected] or your nominated Workforce Officer looking after your recruitment.

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

Position applied for Contact email address:

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

This is regardless of whether the conviction has been issued in the UK or, in any other country where it would be considered
an equivalent (or similar) offence in England and Wales and it is not protected.

It also includes criminal convictions or relevant service discipline convictions received within the Armed Forces Justice
System (e.g. through Summary Hearing or Court Martial) where it would be considered an equivalent offence in England
and Wales and is not protected.

It does not include parking offences. In such cases, you can tick NO.

If you are still unsure about what offences might need to be declared in response this question, please seek advice from
one of the following bodies:
 Nacro – Tel: 0300 123 1999, or email: [email protected]
 Unlock – Tel: 01634 247350, email [email protected] or complete the online form on the Unlock website.

If you have ticked YES, you can choose one of the following options to disclose this information.

Option 1: Please provide details of criminal convictions, military convictions or relevant service discipline convictions,
including the date and reason administered. You may use the continuation sheet attached if you need to.

Option 2: You can provide additional evidence about your criminal conviction, military convictions or relevant service
discipline convictions separately by ticking (√) the box against the statement below. Instructions for returning this
information can be found in bullet point (3) at the top of this form.

I have attached details of my conviction(s) separately

Model declaration form A: To be used for positions which are eligible for a standard or enhanced
DBS check under the Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended)
2. Do you have any cautions, that are not protected (i.e. eligible for filtering) under the Rehabilitation of Please tick
Offenders Act 1974 (Exceptions) Order (as amended)? Yes No

This is regardless of whether the caution has been issued in the UK or, in any other country where it would be considered an
equivalent (or similar) offence in England and Wales and it is not protected.

It also includes cautions that have been issued under military law while serving in the Armed Forces, either in the UK or any
other country, where it would be considered an equivalent offence in England and Wales and is not protected.

If you are still unsure about what offences might need to be declared in response this question, please seek advice from
one of the following bodies:
 Nacro – Tel: 0300 123 1999, or email: [email protected]
 Unlock – Tel: 01634 247350, email [email protected] or complete the online form on the Unlock website.

If you have ticked YES, you can choose one of the following options to disclose this information.

Option 1: Please provide details of cautions including the date and reason administered in the space below.

Option 2: You can provide additional evidence about your caution separately by ticking (√) the box against the
statement below. Instructions for returning this information can be found in bullet point (3) at the top of this form.

I have attached details of my caution(s) separately

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

If you have ticked YES, please provide details 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 you need to.
Model declaration form A: To be used for positions which are eligible for a standard or enhanced
DBS check under the Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended)
4. Are you currently subject to any criminal investigations or pending prosecutions by the police in Please tick
any country which may have a bearing on your suitability for this position? Yes No

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 you need to.

5. Have you ever been subject to any formal action being taken against you by an investigatory Please tick
body in relation to allegations of fraud, which may have a bearing on your suitability for this Yes No
position?

This may include: NHS Counter Fraud Authority (formerly NHS Counter Fraud and Security
Management Services) and/or by an NHS organisation’s local counter fraud specialist, 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, UK Visas and Immigration., or any other investigatory body.

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 you need to.

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

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 you need to.
Model declaration form A: To be used for positions which are eligible for a standard or enhanced
DBS check under the Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended)
7. Are you currently subject to any fitness to practise investigations and/or proceedings by a Please tick
regulatory or licensing body in any country, which may have a bearing on your suitability for this Yes No
position?

If you have ticked YES, please provide the reasons given for the investigation and, if known, the details of any
sanctions being considered on your professional registration including any warnings or interim orders. Please also
include the name and address of the regulatory or licensing body concerned. You may use the continuation sheet
attached if you need to.

8. Have you ever been subject to any sanctions being placed on your professional registration, by a Please tick
regulatory or licensing body in any country? Yes No

This includes: warnings, conditions, limitations, suspension, removal or any other restrictions that have
applied to your professional registration

You are not required to disclose any information in relation to the above if any right to appeal has been
upheld and 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 sanctions and, the name and address of the regulatory or
licensing body concerned. You may use the continuation sheet attached if you need to.

Data protection – please read before signing and return this form
Under the Data Protection Act 2018 we have a legal duty to provide you with information which explains the
lawful basis for collecting special categories of personal data, what it will be used for, who information will be
shared with and how it will be processed.

The Data Protection Act 2018 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 and other similar offences, and security measures.

What will information be used for

The information you provide using model declaration form A 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.
Model declaration form A: To be used for positions which are eligible for a standard or enhanced
DBS check under the Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended)

Who information will be shared with

Access to any such information will be strictly limited to those who are entitled to see it as part of their duties,
and in accordance with our local policy on the correct handling and safekeeping of special categories of
personal data.

How will information be processed

Once a recruitment or other relevant decision has been made NTW Solutions Limited 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. If you have responded YES to any of the questions and are appointed, any information you may
have provided either using this form or separately will need to be retained for a longer period to evidence safe
recruitment practice as part of any scheduled safeguarding audits. The form and any additional information
provided will be kept securely and separately from any personnel records.

Once the retention period has elapsed, any information will be securely destroyed by shredding, pulping or
burning. While awaiting destruction, the secure handling of information as described above, will be adhered to at
all times. It is important for us to make you aware that, while the form and any additional evidence you provide
will be destroyed, we retain the right to keep a record of the type of checks undertaken, the date of these
checks, the position for which the checks were made and justification for the recruitment decision.

Please read the supplementary guidance we provided at the time of your application, as this explains
our policy on the retention and erasure of any such information in full detail. It also outlines your rights
under data protection law.

If you have any queries about completing this form or your rights when declaring information to us, please
contact [email protected]. All queries will be treated in strict confidence.

Declaration
In signing this form, you are agreeing with all four statements outlined below.

1. I confirm that I have read and understood guidance provided which explains how my data will be
processed and I give my consent for enquiries to be made in the way described.

2. I declare that the information I have provided is true to the best of my knowledge and belief.

3. If any information I have declared changes after I have submitted this form, I agree to notify the employing
organisation before my appointment commences.

4. I understand 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.

Full name (in block capitals) Signature

Date
Model declaration form A: To be used for positions which are eligible for a standard or enhanced
DBS check under the Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended)

Continuation sheet
If you have ticked YES to any of the questions above, please use the space below to provide any additional
information you would like 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.

Full name: Position applied for: