Model declaration form B (revised November 2015)
Model Declaration form B
Guidance for employers
This form has been designed to be used by NHS organisations only in connection with
making appointments to positions that are covered by the provisions defined under the
Rehabilitation of Offenders Act 1974 (ROA).
Positions covered by the ROA are non-exempt from the Rehabilitation of Offenders Act
1974 (Exceptions) Order 1975 (as amended); and organisations are only legally
permitted to ask applicants for information in relation to any ‘UNSPENT’ (current)
convictions, cautions, reprimands and final warnings as part of the recruitment process.
Employing organisations must not obtain a standard or enhanced DBS check for nonexempt positions, or require applicants to disclose information about convictions,
cautions, reprimands and final warnings that have become ‘SPENT’ (old).
If an applicant discloses information about spent convictions without being legally
obliged to, the employing organisation cannot act upon that knowledge.
Employers in England and Wales may wish to consider requiring a basic disclosure
through Disclosure Scotland to verify any information that has been declared by
applicants who are applying for non-exempt positions. Further details on how to go
about requesting this level of check can be found on the Disclosure Scotland website.
http://www.disclosurescotland.co.uk/
This form is subject to periodic review. This ensures that any questions posed remain
compliant with requirements under the DBS regime, data protection, human rights and
equality law.
It is essential that organisations refer to the latest information on the NHS Employers
website to ensure they are fully compliant with the current law. This will be particularly
important where questions are raised as part of any locally developed application forms.
Visit our web pages for further information on criminal record and barring check
requirements.
www.nhsemployers.org/your-workforce/recruit/employment-checks/nhs-employment-checkstandards/criminal-record-and-barring-checks
When to seek a self-declaration
This form should be seen as complementary to existing good recruitment practice and
as one part of the overall selection process. It does not substitute the need to carry out
the range of pre-appointment checks that are required by law or are available to
employers.
Model declaration form B (revised November 2015)
We recommend that a self-disclosure is requested from applicants that have been
short-listed for interview. The form should be returned in a separate envelope to the
person in the organisation making the final recruitment decision.
Requiring applicants to complete a self-disclosure as part of your recruitment process
can be useful, as it helps the candidate understand the type of information that will be
requested as part of your employment check processes.
The applicant’s willingness to declare information beforehand gives a fair indication of
their integrity and honesty. It also provides an opportunity for them to discuss the
circumstances surrounding their offending behaviour, and where appropriate, allows
them to demonstrate how they have moved on from their past mistakes, without adding
an additional stage to the recruitment process.
The full range of pre-appointment checks that organisations must obtain when recruiting
in the NHS (within England) are outlined by the NHS Employment Check Standards,
available on our web pages.
www.nhsemployers.org/your-workforce/recruit/nhs-employment-check-standards
Key points to consider

It’s important to make sure you only take into consideration information which is
deemed relevant to the position being recruited to.
Providing guidance to applicants as part of your recruitment pack is therefore key
to ensuring they fully understand what information will be requested from them,
why it is being requested, and at what stage in the recruitment process it will be
requested.
Applicants should also be made aware of how their information will be assessed,
recorded and handled.

Having a criminal record does not necessarily mean an automatic ban to
employment in the NHS. The suitability of an applicant with a criminal record may
vary, depending on the nature of the job, the type of duties that role will involve,
and the relevancy and circumstances of the criminal conviction. Any potential
risks identified at the recruitment stage will need to be handled sensitively and be
assessed on a case by case basis.
Providing a statement which outlines your organisations’ policy when recruiting
applicants with a criminal record will be particularly helpful to reinforce your
commitment to ensuring that all applicants are treated fairly and equally.

Signpost applicants to an individual (within your organisation) who they can talk
to if they have any questions about completing this form, or if they have any
concerns about the type of information that might be revealed about them as part
of your pre-appointment checks.
Providing information about where they can seek independent advice from is also
useful, should they have any concerns about what they may need to disclose.
This might include (but is not exclusive to) a union representative, the Citizen’s
Model declaration form B (revised November 2015)
Advice Bureau, and charitable bodies such as NACRO or Unlock who provide
free advice and support to individuals who have a criminal record. For further
information see our useful links section below.
Changes to legislation
When requiring applicants to complete this form, it is important that you understand the
amendments to the Rehabilitation of Offenders Act, the Exceptions Order and the Police
Act that came into force in May 2013 under Statutory Instrument and March 2014 under
the Legal Aid and Sentencing and Punishment of Offenders Act 2012.

Police Act 1997 (Criminal Record Certificates: Relevant Matters) (Amendment) (England
and Wales) Order 2013 which amends the definition of ‘relevant matters’ in the Police
Act 1997.
Relevant matters specifically refer to non-conviction information that police forces may
deem necessary to disclose as part of a DBS check because of the potential risk to the
vulnerable; and/or where disclosing this information may add relevant
contextual/background to a conviction or a caution which might be invaluable to a
prospective employer. This change came into effect from 29 May 2013.

Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England
and Wales) Order 2013 which amends the Rehabilitation of Offenders Act 1974
(Exceptions) Order 1975 to provide that certain spent (old) or minor convictions and
cautions will become protected under the DBS filtering rules when specific conditions are
met.
This means that as of 29 May 2013, any such information will not be subject to
disclosure as part of a request for a standard or enhanced DBS check; and employers
may not require an applicant to declare this information, or consider this information as
part of their recruitment process.

Legal Aid and Sentencing and Punishment of Offenders Act 2012 (section 139) makes a
number of changes to the Rehabilitation of Offenders Act 1974 in regard to rehabilitation
periods which determine when a conviction or caution can be considered spent.
The changes came into effect from 10 March 2014 but is intended to apply
retrospectively (i.e. any convictions or cautions issued prior to March 2014 will be
deemed spent as defined by the Legal Aid and Sentencing and Punishment of Offenders
Act).
It is important that you understand how this impacts the type of information that may
need to be declared and considered when using this form to ensure you are not
requiring applicants to disclose information they are not legally obliged to.
The questions posed in this model declaration form have been updated to reflect the
changes outlined above. It is important that organisations review their local
recruitment policies to ensure they remain fully compliant with current employment
law. For further clarity about the changes under the DBS filtering rules, see our
useful links section below.
Model declaration form B (revised November 2015)
It’s also important to note that local processes must comply with the Data Protection
Act 1998 (as amended). This includes the handling, storage, retention and sharing of
any information that might be disclosed by an applicant as part of their application or
when providing a self-declaration using this form.
Useful links
Understanding the DBS filtering rules which came into force from 29 May 2013

Listen to our webinar, Understanding the filtering rules, produced with NACRO.
http://www.nhsemployers.org/case-studies-and-resources/2014/11/understandingdbsrules

DBS filtering guide – available on the Disclosure and Barring Service website.
https://www.gov.uk/government/publications/dbs-filtering-guidance/dbs-filtering-guide
Guidance for applicants

Support for people with convictions - Unlock
http://www.unlock.org.uk/support-for-people-with-convictions/information-hub/

Unlock has also produced a really useful disclosure calculator which can be used
to establish whether or not a caution or conviction has become SPENT under the
Rehabilitation of Offenders Act 1974 (as amended in England and Wales)
http://disclosurecalculator.org.uk/

Support for individuals who have a criminal record – jobs and volunteering NACRO
https://www.nacro.org.uk/resettlement-advice-service/support-for-individuals/jobs-andvolunteering/
Model declaration form B (revised November 2015)
Guidance for applicants
IN CONFIDENCE
The position you have applied for is covered by the provisions provided by the
Rehabilitation of Offenders Act 1974 (ROA). This means that it is non-exempt from the
Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended) [the
Exceptions Order], and therefore you are only required to disclose information about
any convictions, cautions, reprimands or final warnings that are ‘UNSPENT’ (current).
You are not required to disclose any information about convictions, cautions,
reprimands or final warnings which have become ‘SPENT’ (old) as defined under the
ROA (as amended by the Legal Aid and Sentencing and Punishment of Offenders Act
2012).
If you have a criminal record, or have received a caution, reprimand or final warning and
are unsure about the type of information you may need to consider declaring as part of
the recruitment process, please refer to the following sources for further guidance:

Support for people with convictions - Unlock
http://www.unlock.org.uk/support-for-people-with-convictions/information-hub/

Unlock has also produced a really useful disclosure calculator which can be used
to establish whether or not a caution or conviction has become SPENT under the
Rehabilitation of Offenders Act 1974 (as amended in England and Wales)
http://disclosurecalculator.org.uk/

Support for individuals who have a criminal record – jobs and volunteering NACRO
https://www.nacro.org.uk/resettlement-advice-service/support-for-individuals/jobs-andvolunteering/
Before you can be considered for appointment with [organisation] we need to be
satisfied about your character and suitability.
[Organisation] 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 recruiting manager. As part of assessing your application,
we will only take into account relevant criminal record and other information declared
which is relevant to the position being applied for.
Model declaration form B (revised November 2015)
The information that you provide in this declaration form will be processed in
accordance with the Data Protection Act 1998. 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 [supplementary guidance notes] sent to you with
your application form before completing this declaration form. These notes provide you
with further and more detailed information about how your application will be processed,
who information will be disclosure to, and the checks that will be done to verify the
information provided.
Please answer all of the following questions.
If you answer ‘YES’ to any of the questions, please use the space indicated to provide
any information that you believe may have a bearing on your suitability for the position
for which you are applying.
Please use the continuation sheet provided in this form to include any additional
information or supplementary comments you wish us to consider in support of your
application. You may continue on a separate sheet if necessary.
It is important to stress that answering ‘yes’ to any of the questions below will not
necessarily bar you from an appointment within the NHS. 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.
1. Are you currently bound over or do you have any current ‘UNSPENT’
convictions, cautions, reprimands or final warnings that have been issued by a
Court or Court-Martial in the United Kingdom or in any other country?
NO
YES


If YES, please include details of the order binding you over and/or the nature of the offence,
the penalty, sentence or order of the Court, and the date and place of the Court hearing.
You are not required to disclose information about any convictions, cautions,
reprimands or final warnings which are SPENT (old) under the Rehabilitation of
Offenders Act 1974.
It is important that you understand the changes that came into effect from March 2014
under the Legal Aid and Sentencing and Punishment of Offenders Act which makes
amendments to the length of time before certain sentences become spent (in England
and Wales only). Before answering this question please refer to further advice and
information under the ‘guidance for applicants’ section above.
You also do not need to tell us about parking offences.
Please include any additional information or comments that you believe to be relevant.
Model declaration form B (revised November 2015)
2.
Have you been charged with any offence in the United Kingdom or in any
other country that has not yet been disposed of?
NO
YES


If YES, please include details of the nature of the offence with which you are charged, date on
which you were charged, and details of any on-going proceedings by a prosecuting body.
You are reminded that if you are appointed, you have a continued responsibility to
inform us immediately where you are charged with any new offence, criminal
conviction, reprimand or final warning, or other relevant proceedings in the United
Kingdom or in any other country that might arise in the future while you are in our
employment.
You do not need to tell us if you are charged with a parking offence.
Please provide any additional information or comments that you believe to be relevant.
3. Are you aware of any current investigations being undertaken by the NHS
Counter Fraud and Security Management Service (NHS CFSMS) following
allegations made against you?
NO
YES


If YES, please include details of the nature of the allegations made against you, and if known
to you, any action to be taken against you by the NHS CFSMS.
Please include any additional information or comments that you believe to be relevant.
4. Have you been investigated by the Police, NHS CFSMS or any other
Investigatory Body resulting in a current conviction or dismissal from your
employment or volunteering position?
NO
YES


If YES, please include details of the nature of the allegations made against you, and if known
to you, any action to be taken against you by the investigatory body.
Investigatory bodies may include: HM Customs and Excise, Inland Revenue, Financial
Service Authority, Department of Trade and Industry, Department of Work and
Pensions, immigration, security agencies, local authorities etc. This list is not
exhaustive, and you must declare any investigation conducted by an investigatory
body.
Please include any additional information or comments that you believe to be relevant.
Model declaration form B (revised November 2015)
5.
Have you ever been dismissed by reason of misconduct from any
employment, volunteering, office or other position previously held by you?
NO
YES


If YES, please include details of the employment, office or position held, the date that you
were dismissed and the nature of allegations of misconduct made against you.
Please include any additional information or comments that you believe to be relevant.
6.
Have you ever been removed from the register or have conditions or
undertakings been made on your registration by a fitness to practise committee,
regulatory or licensing body in the United Kingdom or in any other country?
NO
YES


If YES, please provide details of any conditions or undertakings which have been applied to
your professional registration and the name and address of the regulatory or licensing body
concerned.
You are not required to provide details where any right to appeal has been upheld AND
where that appeal has resulted in your case being fully exonerated.
Please include any additional information, or other supplementary comments that you
believe to be relevant.
7.
Are you currently the subject of a fitness to practise investigation and/or
proceedings by a regulatory or licensing body in the United Kingdom or in any
other country?
NO
YES


If YES, please include details of the reason given for the investigation and, where applicable,
the details of any proceedings, limitations or restrictions that currently apply to your
professional registration, and the name and address of the regulatory or licensing body.
Please include any additional information or comments that you believe to be relevant.
8.
Are you currently subject to any other prohibition, limitation, or restriction
that means we are unable to consider you for the position for which you are
applying?
NO
YES


If YES, please include details.
Please include any additional information or comments that you believe to be relevant.
Model declaration form B (revised November 2015)
9.
Do you know of any other matters in your background which may be
relevant to the position you are applying for, that might cause your reliability or
suitability to be called into question?
NO
YES


If YES, please include details.
You are not required to disclose information about any convictions, cautions,
reprimands or final warnings which are SPENT (old) under the Rehabilitation of
Offenders Act 1974.
It is important that you understand the changes that came into effect from March 2014
under the Legal Aid and Sentencing and Punishment of Offenders Act which makes
amendments to the length of time before certain sentences become spent (in England
and Wales only). Before answering this question please refer to further advice and
information under the ‘guidance for applicants’ section above.
You also do not need to tell us about parking offences.
Please include any additional information or comments that you believe to be relevant.
Model declaration form B (revised November 2015)
Continuation sheet
If you have answered ‘YES’ to any of the questions above, please use this space to
provide any additional information or supplementary comments you wish us to consider
as part of your application. You may continue on a separate sheet if necessary.
Please indicate the number of the question to which the information relates.
Model declaration form B (revised November 2015)
Declaration
IMPORTANT
The Data Protection Act 1998 requires us to advise you that we will be processing your
personal data. Processing includes: holding, obtaining, recording, using, sharing and
deleting information. The Act 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.
The information that you provide in this declaration form will be processed in
accordance with the Data Protection Act 1998. 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, [organisation] will not
retain this declaration form any longer than is necessary - see further details in the
supplementary guidance notes for applicants which we 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.
I have read the supplementary guidance notes for applicants that accompanied my
application form, and I consent to the information provided in this declaration form being
used by [organisation] for the purpose of assessing my application, and for enquiries in
relation to the prevention and detection of fraud.
I confirm that the information that I have provided in this declaration form is correct and
complete. I understand and accept that if I knowingly withhold information, or provide
false or misleading information, this may result in my application being rejected, or if I
am appointed, in my dismissal, and I may be liable to prosecution.
Please sign and date this form.
SIGNATURE ................................................................................................................
NAME (in block capitals) .........................................………...........................................
DATE ...………………………………………………........................................................
Model declaration form B (revised November 2015)
Please complete and return this Model Declaration form in a separate envelope
marked 'confidential'. Forms should be returned to:
NAME.............................................................................................................................
JOB TITLE.....................................................................................................................
ADDRESS......................................................................................................................
........................................................................................................................................
........................................................................................................................................
If you wish to withdraw your consent at any time after completing this declaration form, or you
have any enquiries relating to the type of information required as part of this form, please
contact [insert details of relevant recruiting manager and/or HR].
All enquiries will be treated in strict confidence.