Fitness to Practise (FtP) Declaration Form Fitness to Practise (FtP) Declaration Form CONFIDENTIAL DepartmentName:(Required) First Middle Last Job Role Applied For:(Required)Reg Number (if applicable):(Required)Are you currently bound over, or do you have any convictions or cautions (including warnings and reprimands) which are not deemed ‘protected’ under the amendment to the Exceptions Order 1975, issued by a Court or Court Martial in the United Kingdom or any other country?(Required) Yes No Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of?(Required) Yes No Are you aware of any current NHS Counter Fraud and Security Management Service (CFSMS) investigation following allegations made against you?(Required) Yes No Have you been investigated by the Police, NHS CFSMS or any other Investigatory Body resulting in a current conviction or dismissal from your employment or volunteering position?(Required) Yes No Have you ever been dismissed by reason of misconduct from any employment, volunteering, office or other position previously held by you?(Required) Yes No Have you ever been disqualified from the practice of a profession or required to practice subject to specified limitations/conditions/warnings following fitness to practise proceedings by a regulatory or licensing body in the UK or any other country?(Required) Yes No Are you currently the subject of any investigation or fitness to practise proceeding by any licensing or regulatory body in the United Kingdom or any other country?(Required) Yes No Are you subject to any other prohibition, limitation, or restriction that means we are unable to consider you for any position for which you are applying?(Required) Yes No Do you know of any other matters in your background which might cause your reliability or suitability for employment to be called into question?(Required) Yes No NB: If you are declaring more than one fitness to practise issue/incident, please number each incident when providing further details in the boxes below, and ensure that details are provided as requested for each numbered issue/incident. Please provide a brief summary of the incident(s):Date(s) of the incident(s):Where the incident(s) took place:Final outcome or current state of any investigation(s):A full account of the events leading up to the incident(s):Personal reflection on the incident(s):Any further information that you feel may be important in support of your declaration(s):Name:(Required) First Last Signature:(Required)Your NameYour NameYour NameYour NameDate:(Required)
