Confidential Self-Declaration form

This form is for use by Lead and Assistant Writers as part of our safeguarding procedures. You can find details of our Child Protection Policy here.

The form will only be sent to Jonathan Davidson, our Child Protection Officer.

Dear Lead and Assistant writers

This Confidential Declaration Form applies to paid lead writers and volunteer assistant writers who are likely to be in regular contact with children. This form is strictly confidential and, except under complusion of law, will be seen only by those responsible for the appointment and, when appropriate the relevant safeguarding bodies. All forms will be kept securely under the terms of the Data Protection act 1998.

Please provide us with your name *

Please give us your contact email address *

Have you ever been convicted of or charged with a criminal offence? (including any ‘spent convictions’ under the Rehabilitation of Offenders Act 1974 that are not subject to disclosure & Barring Service filtering rules (see notes 1 & 2 below) *

Have you ever been cautioned by the Police, given a reprimand or warning, or bound over to keep the peace that are not subject to Disclosure & barring Service filtering rules? (see notes 1 & 2 below) *

Are you at present or have you ever been under investigation by the police or an employer for any offence/misconduct that is not subject to Disclosure & Barring Service filtering rules? (see notes 1& 2 below) *

Has a family court ever made a finding of fact in relation to you, that you have caused significant harm (see note 3 below) to a child, or has any such court made an order against you on the basis of any finding or allegation that any child was at risk of significant harm (see note 3 below) from you? *

Has your conduct ever caused or been likely to cause significant harm (see note 3 below) to a child or young person under the age of eighteen, or put a child or young person at risk of significant harm (see note 3 below)? *

To your knowledge, has it ever been alleged that your conduct has resulted in significant harm (see note 4 below) to a child or young person under the age of eighteen or put a child or young person at risk of significant harm (see note 3 below)? *

Has a child in your care or form whom you have or had parental responsibility ever been removed from your care, been placed on the Child Protection Register or been the subject of child protection planning, a care order, a supervision order, a child assessment order or an emergency protection order under the Children Act 1989, or a similar order under other legislation? *

Have you any health conditions which might have health and safety implications in relation to your work with children or young people under the age of eighteen? *

Have you, since the age of eighteen, ever been known by any other name other than that included on your Code of Conduct form? *

Have you, during the past five years, had any home address other than that included on your Code of Conduct form? *

Note One

1. www.gov.uk/dbs search for ‘filtering guidance’ and / or ‘rehabilitation of offenders act’

Note Two

2. Declare all that are not subject to DBS filtering rules (see note 1) including any equivalents obtained abroad except technical motoring offences leading only to a fine and no driving licence endorsements. If you are unsure how to respond you should seek independent advice.

Note Three

3. Significant harm involves serious ill-treatment of any kind including neglect. Physical, emotional or sexual abuse, or impairment of physical or mental health development. It will also include matters such as a sexual relationship with a young person or adult for whom you had pastoral responsibility or were in a position of trust

Get Writing

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Young Writers Magazine

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