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 in full before completing the attached
form)
When assessing your suitability for a position in the NHS, North Cumbria Integrated Care NHS Foundation Trust
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
North Cumbria Integrated Care NHS Foundation Trust 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
Jacqueline Allen, Team Lead Recruitment, [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
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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)
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.
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
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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)
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 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 the Recruitment Officer dealing with
your appointment.
Applicant details
Full name (in block JUNAID RASOOL Contact telephone no: 07436597051
capitals) BAKHSH
Position applied for Consultant Contact email [email protected]
address:
Please
1. Do you have any criminal convictions that are not protected (i.e. eligible for filtering) under the tick
Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended)? Ye No
s
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.
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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)
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
2. Do you have any cautions, that are not protected (i.e. eligible for filtering) under the Please
Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended)? tick
Ye No
s
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
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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)
3. Have you been formally charged with any other offence in any country which has not Please
yet been disposed of? tick
Ye No
s
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.
4. Are you currently subject to any criminal investigations or pending prosecutions by the Please
police in any country which may have a bearing on your suitability for this position? tick
Ye No
s
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 Please
investigatory body in relation to allegations of fraud, which may have a bearing on your tick
suitability for this position? Ye No
s
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.
5
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)
6. Have you ever been dismissed for misconduct from any employment, volunteering, office, or Please
other position previously held by you, in circumstances which may have a bearing on your tick
suitability for this position? Ye No
s
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.
7. Are you currently subject to any fitness to practise investigations and/or proceedings Please
by a regulatory or licensing body in any country, which may have a bearing on your tick
suitability for this position? Ye No
s
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, Please
by a regulatory or licensing body in any country? tick
Ye No
This includes: warnings, conditions, limitations, suspension, removal or any other restrictions s
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.
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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)
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.
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 North Cumbria Integrated Care NHS
Foundation 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. 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.
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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 you have any queries about completing this form or your rights when declaring information to us, please
contact the Recruitment Officer dealing with your appointment. 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 JUNAID RASOOL Signature
capitals) BAKHSH
Date 30/12/2022
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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:
