Confidential Safeguarding Self Declaration Form DBS 4

Confidential Safeguarding Self Declaration Form DBS 4

If you have a disability that may make the completion of this form difficult, it can be completed by someone on your behalf however you are required to sign and date the form.

This form can be returned in a sealed envelope - You can download a PDF version of this form here or on the right-hand side of this page

This form will be retained for 10 years and 1 day after the person leaves role or will be superseded by a new DBS 4 when a new application is processed, refer to document retention policy for further details.

Please state your CARE HOME, PARISH, RELIGIOUS ORDER or ORGANISATION:

Please state the CHURCH you belong to within your PARISH if applying for a parish role:

Please state ALL ROLES you undertake at CARE HOME/ALL PARISHES / RELIGIOUS ORDERS / ORGANISATIONS:

Status of Role:

Employed

Voluntary

Post Holder

Title

Current Full Name

State an PREVIOUS NAMES including any BIRTH NAMES if you have been MARRIED or if THE NAME YOU ARE USING IS DIFFERENT TO YOUR BIRTH NAME and provide ALL DATES YOU USED THOSE NAMES e.g. from (dd/mm/yyyy) to (dd/mm/yyyy)

You must provide proof of all name changes, if you are unable to do so you must provide the ID Verifier with a satisfactory explanation

Date

DD slash MM slash YYYY

Place of Birth

Full Address including Postcode and the date you moved into your current address (dd/mm/yyyy):

Please provide details of previous addresses if you have lived at your current address less than 5 years.

Full Address including Postcode:

Dates from and to (dd/mm/yyyy)

Full Address including Postcode:

Dates from and to (dd/mm/yyyy)

Home Telephone Number:

Mobile Telephone Number:

National Insurance Number

Please state your CURRENT NATIONALITY:

Please state your BIRTH NATIONALITY:

Are you registered with the ONLINE UPDATE SUBSCRIPTION SERVICE?

Yes

Don't Know

Update Service and other DBS online services - GOV.UK

Please state your preferred method of contact:

Post

Telephone

The amendments to the Rehabilitation of Offenders Act 1974, (Exceptions) Order 1975 (2013 and 2020) provide that when applying for certain jobs and activities, certain convictions and cautions are considered ‘protected’. This means that they do not need to be disclosed to employers, and if they are disclosed, employers cannot take them into account.

Question 1 of 4:

Do you, the applicant, have any convictions (excluding youth cautions) which would not be filtered in line with current guidance?

Yes

If YES please provide summary details below:

Question 2 of 4:

Have you ever been accused of inappropriate conduct within an employed or voluntary capacity?

Yes

If YES please provide summary details below:

Question 3 of 4:

Have you ever received a caution or conviction from another country outside of the UK?

Yes

If YES please provide summary details below:

Question 4 of 4:

Are you, or have you even been the subject of an investigation into a concern about a child in your care or investigated under adult protection safeguarding procedures, or are you currently the subject of a police investigation?

Yes

If YES please provide summary details below:

Data Protection Act Declaration (please read, sign & date)

Knowyourpeople (hereafter known as KYP), now working in partnership with the Catholic Safeguarding Standards Agency, is registered with the Disclosure & Barring Service (DBS) for processing criminal records checks. Individuals working in diocesan offices, parishes, religious congregations and Catholic Organisations (where agreed with CSSA), who carry out criminal record check processes via the DBS are ‘agents’ of the CSSA and are bound by the policies of the DBS, KYP and the Catholic Church national safeguarding procedures for DBS application processing and the DBS Code of Practice.

I have been provided with a copy of the Privacy-notice-for-DBS-applications-updated-August-2025.docx and KYP privacy notice KnowYourPeople-KYP-privacy-policy.doc and I understand how KYP, CSSA and its Agents will process my personal data(Required)

I consent to my application being processed online by KYP and CSSA(Required)

I have read the Standard/Enhanced Check Privacy Policy for applicants and I understand how DBS will process my personal data and the options available to me for submitting an application(Required)

I have read the Standard/Enhanced Check Privacy Policy for applicants and I understand how DBS will process my personal data and the options available to me for submitting an application.(Required)

I consent to the DBS providing an electronic result directly to the registered body that has submitted my application. I understand that an electronic result contains a message that indicates either the certificate is blank or to await certificate which will indicate that my certificate contains criminal record information. In some cases, the registered body may provide this information directly to my employer prior to you receiving the certificate. I understand if I do not consent to an electronic result being issued to the registered body submitting my application that I must not proceed with this application, and I should submit a paper application form. I understand that to withdraw my consent whilst my application is in progress I must contact the DBS helpline 03000 200190(Required)

I acknowledge that information may be transferred by First Advantage to affiliates and/or sub processors to the extent necessary to assist with the checks. During the background check process of your personal data may be disclosed to law enforcement and government agencies to check for civil and criminal records, as permitted by law. Sources of information used during the vetting process may include government authorities and third parties, such a prior employers and educational institutions you attended. In order to meet processing requirements from certain sources (DBS, etc), you acknowledge that special characters from the data provided may be removed if required to fulfil one or more checks. I hereby confirm that I am of legal age to confirm the above statements. If not, I confirm that this has been approved by my parent or guardian.(Required)

Date

DD slash MM slash YYYY

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