Request for a criminal records poc(NI) & pova(NI) check




Дата канвертавання24.04.2016
Памер27.32 Kb.
(For use by Statutory Bodies only) POCVA (NI) 1

REQUEST FOR A CRIMINAL RECORDS POC(NI) & POVA(NI) CHECK

I
REF NO: ST1129
N CONFIDENCE


COMPLETE IN BLOCK CAPITALS


To: The Chief Constable

Criminal Records Office

PSNI

Brooklyn


Knock Road

BELFAST


BT5 6LE


From: Register Of Support Providers

Room 24B10

Student Support

University Of Ulster at Jordanstown

Shore Road

Newtownabbey

County Antrim

Postcode: BT37 0QB


Tel No: 028 90 366936

Fax: 028 90 366836

Email: supportregister@ulster.ac.uk


ALL INFORMATION MUST BE SUPPLIED. THE ACCURACY OF THE CHECK DEPENDS ON THE ACCURACY OF THE PERSONAL DETAILS PROVIDED. IF NOT APPLICABLE, ENTER N/A

Mr/Mrs/Miss/Ms

(enter as applicable)



Date of Birth

National Insurance No




























Surname:

Previous Surname(s)

Full Forenames:

Address:




Postcode:

Please list ALL previous addresses below:

Address:




Postcode:

Address:




Postcode:

Address:




Postcode:

P

revious addresses continued overleaf? Yes No




H

ave all Convictions/Cautions been declared? Yes OR No Convictions/Cautions to declare None




Has the applicant ever been the subject of an investigation alleging that they were the perpetrator of adult or child abuse?

Y

es No


If Yes, please give dates, details and outcome of all incidents.

_____________________________________________________________________________________________________

________________________________________________________________________Please continue on separate sheet)


Please mark with “X” in one box only – This request is to be checked against the Disqualification List/s pertaining to:-

P

rotection of Children only Protection of Vulnerable Adults Only BOTH:



  • I am satisfied that the particulars given above are accurate and that the above-named person has given written permission for the check to be made and is aware that any spent convictions will also be disclosed.

  • I further declare that any information given will be treated in strict confidence and used only in accordance with the Department’s guidance and the information provided will be used to complement sound recruitment practices.

  • I confirm that this check is for a post which is a regulated position under Article 31 and/or a care position as defined in the booklet “Choosing to Protect” relating to Vulnerable Adults (Para 2.2 refers).

SIGNED: ________________________ NAME IN CAPITALS: ____________________ DATE: ______________

(Original signature of nominated/deputy nominated officer)
_____________________________________________________________________________________________________

TO BE COMPLETED BY POLICE

No trace on details supplied The subject may be the individual to whom attached information refers


SIGNED: ____________________________ RANK: ______________ DATE: _________________


APPENDIX 5
INFORMATION ABOUT AND CONSENT TO THE PROTECTION OF CHILDREN (POC)(NI) AND/OR VULNERABLE ADULTS (POVA)(NI) SERIVCES CHECK BY APPLICANTS FOR POSTS INVOLVING WORK WITH CHILDREN AND/OR VULNERABLE ADULTS
You have applied for a post which is governed by The Protection of Children and Vulnerable Adults (Northern Ireland) Order 2003. Before appointing anyone to such a post, it is our policy to ask for the relevant check to be carried out by the Department of Health, Social Services and Public Safety (DHSSPS). This check is to make sure that individuals who might be a risk to children and/or vulnerable adults are not appointed.
The check will tell us if you have a criminal record, or if your name is included on the DHSSPS Disqualification from Working with Children List or included on the DE List and/or the DHSSPS Disqualified from Working with Vulnerable Adults List. Any information received will be treated confidentially, and we will talk to you about it before a final decision is reached. After the decision is made the information will be destroyed. (Employment/Nursing Agencies and Employment Businesses will retain this information for 12 months).
A check will only be carried out if you are considered to be the preferred candidate and are being offered an appointment. You must tell us now if you have ever been convicted of a criminal offence, or cautioned by the police, or bound over. You must tell us about all offences, even minor ones such as motoring offences, and ‘spent’ convictions, that is, things which happened a long time ago. If you leave anything out it may affect your application.
Please complete the section below and return it with your application. The form also asks you to give your written consent to the check. If you do not consent we will not accept your application.

_____________________________________________________________________________________________


CONSENT TO *POC(NI) CHECK AND/OR *POVA(NI) CHECK (*delete one if necessary)
Do you have any prosecutions pending YES/NO (if yes, please give details)

___________________________________________________________________________________________


___________________________________________________________________________________________
Have you ever been convicted at a court or cautioned by the police for any offence? YES/NO
If yes, please list below details of all convictions, cautions, or bind-over orders. Give as much information as you can, including, if possible, the offence, the approximate date of the court hearing and the court which dealt with the matter.

___________________________________________________________________________________________


___________________________________________________________________________________________
Have you ever been the subject of an Adult or Child Abuse investigation which alleged that you were the perpetrator of any adult or child abuse? YES/NO
If yes, please list full details below. If possible please provide the approximate date/s.
___________________________________________________________________________________________
___________________________________________________________________________________________
I understand that a POC(NI) and/or POVA(NI) Service checks/s (as specified above) must be carried out before an offer of appointment can be confirmed. This has been explained to me and I am aware that spent convictions may be disclosed. I declare that the information I have given is accurate and I consent to the check being made.
SIGNATURE: ____________________________ DATE: ______________________
NAME: ____________________________

Position Applied for: __________________________________________________________


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