Full Name:
UCAS Personal ID number:
Programme applied for: ……………………………………………………
Contact email: ……………………………………………………………….
Internal Declaration of Criminal Convictions, Cautions, Reprimands or Warnings
Your chosen route of study is exempt from the provisions of Section 4 (2) the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. This means that you must declare ALL criminal convictions, cautions, reprimands, or warnings even if they are spent (e.g. you think they have been removed from the records or were juvenile offences), and include those outside of the United Kingdom. Admissions will organise police clearance through the Disclosure and Barring Service(DBS) for all students after an offer has been made and accepted and this disclosure will reveal all convictions, cautions, reprimands or warnings received at any time whether as a juvenile or an adult.
You may have been asked if you have any criminal convictions earlier in your application process (i.e. on your UCAS form). We note this but need to ask you about your warnings, cautions and convictions as part of our internal criminal records check process and to meet our legal requirements to ensure DBS checks are completed accurately. DBS checks are an on-going part of the accountability of health professionals and you will need to give information about warnings, cautions and convictions on subsequent occasions should you be successful in working towards registration as a healthcare professional.
If youdo not disclose offences which come to light later, as a result of theDBS, your application will be subject to the University’sCriminal Records panelprocedure by which all undisclosed cases are considered by senior and programme staff, the outcome may result inyour withdrawal/deferred entry from the course. Information you disclose will only be used for the purpose of considering your application to the applied programme and will only be shared with those who need to use this information for this purpose.
Please note that any disclosures are not part of the admissions decision. However, your entry onto your chosen programme is conditional on satisfactory clearance. If you answer ‘yes’ to any of the questions below, please provide further details as indicated.
If you have any questions, please contact Admissions at .
Have you ever received any cautions, convictions, reprimands or warnings in the UK or any other country? Has a Court or Court Martial ever convicted you of any offence or are you currently bound over?
□ NO / □ YES Please provide details below.
- Date of conviction, caution, reprimand, warning or Court Martial
- Nature of conviction, caution, reprimand, warning or Court Martial
- Clarification of conviction, caution reprimand, warning, or Court Martial. Please include date and penalty received (you may wish to continue on another sheet)
Have you been charged with any offence in the United Kingdom or any other country that is currently still under investigation or is there any current police investigation following allegations made against you?
□ NO / □ YES Please provide details below.- Date on which you were charged
- Nature of offence for which you have been charged or allegations made
- Details of any on-going proceedings by a prosecuting bodyor action to be taken against you by the police authorities (you may wish to continue on another sheet)
We may need to ask you for more details about any declared offences and will do so via the email you have provided above.
Internal Declaration of Employment Disciplinary Proceedings
If you have had your professional registration suspended or revoked, or undergone a disciplinary/fitness to practise investigation in the UK or any other country, please provide further information. This will be reviewed by an Admissions Panel and you may be required to provide full copies of related documentation. Any information you disclose will only be used for the purpose of considering your application to the applied programme and will only be shared with those who need to use this information for this purpose.
Have you ever been dismissed due to misconduct from any employment, office or other position previously held by you? Have you ever been disqualified from the practice of a profession or been subject to specified limitations or restrictions following fitness to practice proceedings? Are you currently the subject of any investigation or fitness to practice proceedings?
□ NO / □ YES Please provide details below.- Date on which you were dismissed or disqualified
- Details of the office or position held
- Details of the nature of allegations of misconduct made against you or disqualification (you may wish to continue on another sheet). Please include details of any subsequent limitations or restrictions on your employment. Include the name and address of the licencing or regulatory body involved
Members of Registered Professional Bodies
If you are a current healthcare professional or a member of a registered professional body, we require that you provide details of your registration:
Registration body: ………………………………………………………………………………………
Start and end date of registration: …………………………………………………………………...
Pin or membership number: ………………………………………………………………………….
Please state previous Education at another Higher Education Institution (HEI)within the UK, EU or overseas.
With reference to the above, have you interrupted, been excluded, discontinued or failed to complete an award at a previous HEI?
Signed: Date: