HEADTEACHER: Mr S Smith 01642 581716

Staff Disqualification Declaration Form

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In completing this form, I confirm that the information provided is true to the best of my knowledge and that:

I understand my responsibilities to safeguard children.

I understand that I must notify the headteacher immediately of anything that affects my suitability including any cautions, warnings, convictions, orders, or other determinations that would render me disqualified from working with children.

Employee disqualification declaration form

Staff Details

Name
Name
First
Last

Section 1 – Orders or other restrictions

Have any orders or other determinations related to childcare been made in respect of you?
Have any orders or other determinations related to childcare been made in respect of a child in your care?
Have any orders or other determinations been made which prevent you from being registered in relation to childcare, children’s homes or fostering?
Are there any other relevant orders, restrictions or prohibitions in respect of you as set out in the Schedule 1 of the Regulations?
Are you barred from working with children?
Are you prohibited from teaching?

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?
Have you ever been cautioned, reprimanded, given a warning for, or convicted of any violent or sexual offence against an adult?
Have you ever been cautioned, reprimanded, given a warning for, or convicted of any offence under the Sexual Offences Act?
Have you ever been cautioned, reprimanded, given a warning for, or convicted of any offence under Schedule 2 (Repealed Statutory Offences)?
Have you ever been cautioned, reprimanded, given a warning for, or convicted of any offence under Schedule 3 (Specified Offences)?
In relation to the questions within section 1 and section 2 above, have you ever been cautioned, reprimanded, given a warning for, or convicted of any similar offence in another country?

Section 3 – Provision of information

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