Health and Criminal Conviction Disclosure

Title *

Full name *

Include forenames in full, maiden name and surname.

Have you ever been subject to disciplinary or misconduct issues whilst working in care? *

Present Health

Do you have any health problem(s) which are relevant to your application? *

Do you have or have you ever suffered from back problems? *

Rehabilitation of Offenders Order 1979

Do you have any convictions that are not “protected” as defined by the Rehabilitation of Offenders (Exceptions) (Northern Ireland) Order 1979, as amended in 2014 *

A criminal record will not necessarily disqualify you from obtaining a position, BFS Healthcare has a policy on the recruitment of ex-offenders, which can be made available on request.

Access NI

Access NI Enhanced Disclosure with Barred Checklist

As part of your enhanced disclosure check, this will include a search of the barred checklist.

Are you on any barred checklist? *

Is there any reason why you may not be able to work in regulated activity?* *

*Please note it is a criminal offence to apply to work in this sector if you are listed on the barred checklist. Working with children and vulnerable adults in ‘regulated’ activity, as defined by the Safeguarding Vulnerable Groups (NI) Order 2007, is regarded as exempt from the Rehabilitation of Offenders (NI) Order 1978.

This means all convictions must be declared and will be recorded on your disclosure certificate from Access NI - failure to disclose any cautions or convictions will result in your application being disqualified to work for BFS Healthcare.

BFS Healthcare complies and follows the Access NI code of practice in relation to the requirements, submission, processing and handling of all candidate disclosure requests. All disclosure requests will be at the appropriate level for the role applied. A copy of the Access NI Code of Practice which can be found at: https://www.nidirect.gov.uk/publications/accessni-code-practice and made available upon request.

Access NI operates under the provisions of Part V of the Police Act 1997. All nurses and care staff will be asked to apply for an Access NI Enhanced Disclosure as part of the recruitment and selection process. Any additional information relevant after commencement of employment must correspond to BFS Healthcare:

I agree to the above:

Signature *

Clear Signature

SIGNATURE OVER PRINTED NAME

Add your signature by drawing with a mouse or touchscreen device.

Date *

Health and Criminal Conviction Disclosure

Health and Criminal Convicton Disclosure

Access NI