Agency Worker Childcare Disqualification Questionnaire

Candidate ID*

Candidate Unique Key*

Full Name*

School

Have you been cautioned for or convicted of certain violent and sexual criminal offences against children and adults?*

Yes
No

Are there any grounds relating to the care of children (including where an order is made in respect of a child under your care)?*

Yes
No

Has your registration been refused or cancelled in relation to any application you have made for childcare work or working in children’s homes or been disqualified from private fostering?*

Yes
No
Not Applicable

Are you living in the same household with another person(s) who would answer “YES” to any of the above questions?*

Yes
No

If you have answered YES to one or more of the above questions, please provide details below. Please note that this does not automatically affect your employment and each case will be considered against Child Protection guidelines.

Further Information*

I can confirm that I have answered the statements above truthfully to the best of my knowledge and if any circumstances change I will inform the Company immediately.

Your Signature*

Sign as appropriate for your device using either your finger, trackpad or mouse

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