DBS Self Declaration & Consent Form

The position you have applied for has been identified as being ‘Eligible Position’ under the Rehabilitation of Offenders Act
1974 (Exceptions) Order 1975 (as amended) (the Exceptions Order), the Police Act 1997 (Criminal Records) Regulations (as
amended) and the Safeguarding Vulnerable Groups Act 2006 (as amended by the Protection of Freedom’s Act 2012). As
such, it is eligible for a Standard or an Enhanced level disclosure to be requested through the Disclosure and Barring Service
(DBS).


Both Standard and Enhanced level DBS disclosures contain information about an applicant’s spent and unspent convictions,
cautions and reprimands. Enhanced level disclosures may also include other relevant police information.


Please be aware that the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales)
2013 provides that certain spent convictions and cautions will become protected when specific conditions are met and
therefore are not subject to disclosure through a DBS criminal record check, and employers cannot take these into account.
Guidance and criteria on the filtering of these cautions and convictions can be found on the Disclosure and Barring Service
website at: www.gov.uk/government/disclosure-and-barring-service


Before you can be considered for appointment in an activity involving contact with vulnerable groups with Melody Care we
need to be satisfied about your character and suitability.


Where the position has, in addition been identified as a Regulated Activity under the Safeguarding Vulnerable Groups Act
(2006) (as amended by the Protection of Freedom’s Act 2012) an Enhanced level DBS disclosure will include information
which is held on the Children’s and/or Adults barred list(s), as applicable to the position.


Melody Care aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on
merit regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation,
pregnancy or maternity, marriage or civil partnership. We undertake not to discriminate unfairly against applicants on the
basis of criminal conviction or other information declared.


Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that
we believe may have a bearing on your suitability for the position. If we do not raise this information with you, this is
because we do not believe that it should be taken into account. In that event you still remain free, should you wish, to
discuss the matter with the interviewing panel. As part of assessing your application, we will only take into account relevant
criminal records and other information declared.


The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 2018.
It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries
in relation to the prevention and detection of fraud.


Please ensure that you read the ‘Guidance Notes for Applicants’ that accompanied your application form
carefully before completing this declaration form. They provide you with further and more detailed information about
how your application will be processed, the persons to whom it will be disclosed and the checks that will be done to verify
the information provided.


Please answer all of the following questions in this form. If you answer “yes? to any of the questions, please provide
full details in the space indicated. 


Answering ‘yes’ to any of the questions below will not necessarily bar you from an appointment with Melody
Care. This will depend on the relevance of the information you provide in respect of the nature of the position
for which you are applying and the particular circumstances.

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1. Are you currently bound over, or do you have any current unspent convictions or cautions, or have you ever been convicted of any offence by a Court or Court-Martial in the United Kingdom or in any other country?
2. Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of?
3. Are you aware of any current investigation being undertaken by the NHS Counter Fraud and Security Management Services (NHS CFSMS) following allegations made against you?
4. Have you been investigated by the Police, NHS CFSMS or any other Investigatory Body resulting in a current or past conviction or dismissal from your employment or volunteering position?
5. Have you ever been dismissed by reason of misconduct from any employment, volunteering, office or other position previously held by you?
6. Have you ever been disqualified from the practise of a profession, or required to practise subject to specified limitations following fitness to practise proceedings, by a regulatory or licensing body in the United Kingdom or in any other country?
7. Are you currently or have you ever been the subject of any investigation or fitness to practise proceedings by any Licensing or Regulatory Body in the United Kingdom or in any other country?
8. Are you subject to any other prohibition, limitation, or restriction that means we are unable to consider you for the position for which you are applying?
9. Do you know of any other matters in your background which might cause your reliability or suitability for employment to be called into question?
DECLARATION IMPORTANT: The Data Protection Act 2018 requires us to advise you that we will be processing your personal data. Processing includes: holding, obtaining, recording, using, sharing and deleting information. The Data Protection Act 2018 defines 'sensitive personal data' as racial or ethnic origin, political opinions, religious or other beliefs, trade union membership, physical or mental health, sexual life, criminal offences, criminal convictions, criminal proceedings, disposal or sentence. Where you are applying for a position which involves regulated activity, this will also include any barring decisions made by the Disclosure and Barring Service (DBS) against the Children's or Adults Barred Lists under the terms of the Safeguarding Vulnerable Groups Act 2006 (as amended by the Protection of Freedom's Act 2012). The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 2018. It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud. Once a decision has been made concerning your appointment, Melody Care will not retain this declaration form any longer than necessary (see further details in 'Guidance Notes for Applicants' which was provided with your application form). This declaration will be kept securely and in confidence. Access to this information will be restricted to designated persons within the organisation who are authorised to view it as a necessary part of their work. In signing the declaration on this form, you are explicitly consenting for the data you provide to be processed in the manner described above. Please sign this form.
If you wish to withdraw your consent at any time after completing this declaration form or you have any enquiries relating to information required in this form, please contact the Recruitment Team on 01252 229360. All enquiries will be treated in strict confidence.