Interview Questionnaire

This form should be completed by:

• All individuals making up an organisation whose sole purpose is to provide early years childcare,

Which includes:

Anyone who works with three or more other people on domestic premises

Anyone who works for a registered childminder as an assistant

Anyone working directly with children as a staff member or assistant of a childcare provider on domestic premises

Anyone aged 16 years or over who lives or works on the premises where early years

Childminding or childcare on domestic premises takes place or is to take place.

Please use the additional information sheet at the end of the form if necessary.

If you need any help to complete this form, please contact us on: 07538411005

Section C - Personal Details

(C1-C10) This section asks for basic information about you. We hold this information about you to help us carry out checks to establish if you are suitable to look after children and to make sure that we do not mistake you for anyone with a similar name.

(C2) Current First name(s) (in full)

(C3) Current Last name

(C4) Have you previously been known by a different first name or last name to those entered at C2 and C3?

Yes

If 'Yes', please provide all previous names and dates used (Most recent first).

(C5) Date of Birth:

(C6) Born in the UK:

Yes

If 'No', please specify:

(C7) Place Of Birth (Town/City):

(C8) Place of Birth (County):

(C9) Nationality:

(C10) Gender:

Female

Male

Other

Section C personal details continued - (C11–C14)

We need to know where you have lived for the last five years, including the dates you moved in and out of each address. It is important that you give the full postal address including the postcode. You should include any overseas addresses if applicable.

Please provide the details of all other addresses where you have lived in the last five years. You must provide five years of continuous addresses including any overseas addresses as applicable.

Please use the additional information sheet at the end of this form if necessary.

If you have lived outside the United Kingdom within the last five years, in certain circumstances we will ask you to obtain a police check or certificate of good conduct from any country in which you have lived. You must give an account for every period of time you have lived outside of the United Kingdom, for example travelling on a gap year.

You must explain in full any gaps in your address history during the past five years, so that you include a full record of the whole five year period.

(C11) Have you lived outside the UK in the past five years?

Yes

(C12) Current Full Postal Address:

Postcode:

I have lived here from:

List of other Addresses and the dates you were there from and to:

(C14) Do you have any time unaccounted for in the last five years (starting with the most recent)

Yes

If 'Yes' please list (include where, when did you start living there and for how long):

Section D - Contact Details:

(D1) This section asks for information about other ways we can get in touch with you.

Please tell us your main telephone contact number and email address.

We may use email to contact you. Please give your email address and

indicate this as your preferred method of contact.

You must provide a secure email address that is not accessed by anyone other than you. This is because we may need to send personal information that must only be accessed by you.

If you tick ‘yes’ to the question about communicating with you electronically then we will send as much correspondence as we can to the email address that you have provided.

(D1) Contact telephone numbers (include area code):

Main Contact number:

Landline

Mobile Phone

Other

Email Address

Section F – Previous experience of being a carer

This section should only be completed if you are:

an individual making up the registered person whose prime purpose is to provide childcare and

you intend to work directly with children.

This section asks about any relevant experience, qualifications or training that you have. Please use

the additional information sheet at the end of the form if necessary.

(F1) Please give details of any relevant experience that you have, including:

as a foster parent

as a previous registered provider

caring for children

voluntary childcare work.

(F2) Please give details of any relevant training or qualifications.

(F1) Experience:

Full Postal Address:

From:

To:

(F1) Experience:

Full Postal Address:

From:

To:

(F2) Relevant childcare training and qualifications:

Title of course; Awarding Body and Date Completed (If not, please type 'N/A'):

Section G – Health details

This section should only be completed if you are:

A person who will look after children with a registered childminder

A person aged 16 or over who lives or works on the premises where childminding will take place

A person aged 16 or over who lives or works on domestic premises where childcare will take place.

(G1–G3) We ask for details about your medical history and your GP. Normally, this information will not affect you working with or being in contact with children.

Where there are concerns, Ofsted’s medical advisers assess the information and may contact you or your doctor for further details.

Ofsted’s medical advisers assess this information to make sure you are medically fit to look after or be in contact with children.

(G1) Have you had any serious illnesses within the last five years?

Yes

If 'Yes', please give details below:

From:

To:

(G2) Have you been admitted to hospital in the last two years?

Yes

If 'Yes', please give details below (reason for admission):

From:

To:

(G3) Are you currently being treated by your GP, another doctor or a hospital?

Yes

If 'Yes', please give details below (reason for admission):

Section H - Referees

This section should only be completed if you are:

An individual making up the registered person and you intend to work directly with children.

(H1–H2) We need references to confirm your your suitability to provide childcare. Please give the names and addresses of two people from whom references may be obtained.

Relatives cannot give you a reference. You may use a reference from a friend, neighbour or colleague who knows you well.

Where possible, these should be individuals who have known you in a childcare role and/or for a significant period of time (12 months or more).

Please ask your referee to reply to our request for references promptly. We will not be able to register you until they have submitted their reference.

In addition to supplying the names and addresses of your two referees, you may also enclose written references from these people if you wish. This may help us process your application more quickly.

We check a sample of references supplied in this way with the individuals concerned.

References should include information on:

The referee’s full name, address and telephone number

How long the referee has known you

The capacity in which the referee has known you

The present relationship between yourself and the referee

The referee’s opinions of your ability to look after children and your overall character/suitability and any other relevant information.

(Reference 1)Title and First name

Last name

Country/Region

Address

City

Zip / Postal code

Phone number:

How do they know you:

How long have they known you? (More than 12 months)

Have you got a reference with you?

Yes

(Reference 2)Title and First name :

Last name:

Country/Region

Address

City

Zip / Postal code

Phone number:

How do they know you:

How long have they known you? (More than 12 months)

Have you got a reference with you?

Yes

Section I – Suitability and disqualification

(I1) You must complete this section in full, otherwise the form will be returned to you. We need to check if there are certain circumstances that will prevent you from working with or being in regular contact with children, or bring into doubt your suitability. This section helps us decide if you are suitable to apply or if there are any other circumstances that might affect your suitability.

Please use the additional information sheet at the end of this form if necessary.

Some people are disqualified from providing or working in childcare. Some of the things that disqualify people from working with children are:

Having committed certain offences against a child

Having committed certain offences against an adult (for example murder, kidnapping, rape, indecent assault, assault occasioning actual bodily harm)

Being included on the list of those who are barred from working with children, held by the Independent Safeguarding Authority1

Having been charged with certain offences against an adult, or an offence that is related to an offence, and had a relevant order imposed

Having been made the subject of a disqualifying order

Having been made the subject of an order or determination where a child has been removed from their care or been prevented from living with them

Having been refused registration as a childcare provider or have had a registration cancelled (other than cancellation for non-payment of the fee for continued registration after 1 September 2008)

2 Living on the same premises as another individual who is disqualified for one of the above reasons.

(I3) We make a decision about your suitability by carrying out a series of checks, including a check with the Criminal Records Bureau. You must give us details of any conviction by a court, or any caution, reprimand or warning issued to you by the police – this still counts as a criminal record even if you accepted it voluntarily. You must include all instances where this has happened – even if it happened a long time ago, or when you were a juvenile, or where you did not receive a custodial sentence. Please note that exemption under the Rehabilitation of Offenders Act 1974 that allows some offences to be treated as ‘spent’ does not apply in this context. This means we need to know about all such matters so we can consider whether they disqualify you or may affect your suitability to care for, or be in contact with, children. Not all offences prevent you from working with or being in regular contact with children.

You need to include:

The nature of the offence

The place where the offence occurred

The name of the court that gave the conviction

The penalty imposed.

(I4) We will return all documents to the address at C12 by recorded delivery.

(I1) Do any of the circumstances listed in the guidance above on suitability and disqualification apply to you?

Yes

If 'Yes' please specify which circumstances apply:

(I2) Have you ever been involved with social services in respect of your own children?

Yes

If 'Yes' please give details below:

(I3) Have you ever been convicted of any criminal offences or been given a caution?

Yes

If 'Yes', please fill out the details below:

Date of the offence:

If 'Yes', please give details:

Date of the offence:

If 'Yes' please give details:

(I4) Do you already hold a Enhanced Disclosure and Barring Service (DBS) Certificate?

Yes

If you have answered ‘YES’, please ensure the original Certificate, has been scanned by us and we will add it to your personal file.

Are you signed up to the Enhanced Disclosure and Barring Service (DBS) update service?

Yes

(I5) Are you aware of any other circumstances that might affect your suitability to work or be in regular contact with children?

Yes

If 'Yes', please give details:

I consent to ADC carrying out checks and using information provided from the checks and this consent form.

I understand that ADC will share any information they obtain about me with other organisations where the law requires them to, including where information raises concerns of a child protection nature.

I consent to ADC sharing information about my application with inspection service providers who, under law, are permitted to carry out regulatory processes on behalf of ADC.

I declare that all the information I have given on this form is true to the best of my knowledge and belief.

Please sign here:

What happens to the information provided?

ADC processes your personal information in accordance with the Data Protection Act 1998. Under the Act you have certain rights regarding access to the personal information that ADC holds about you. You can

ask to see this personal information. You should contact Ofsted if you wish to make such a request. We may get information about you from others, or we may give information to them. We will only do so in accordance with the law. We may check information we receive about you with what is already in our records. This can include information provided by you as well as by others, such as other government departments and agencies. We will not give information about you to anyone unless the law permits us to do so.

The law states that we can give information to:

Parents – to help them in choosing a childcare provider

Local authorities – so that they can include details such as names, addresses and other registration information in their family information services

Ofsted’s inspection service providers who, by law, carry out regulatory processes on our behalf

His Majesty’s Revenue and Customs – so that it can check on tax credit eligibility for parents using childcare

Other government departments or agencies – if they ask for information about a provider in a written request and the information is needed for child protection purposes

Child protection agencies and the police – so that they can investigate circumstances where children might need protecting from harm.

Information you supply can be given to these people and organisations because the Childcare Act 2006 (sections 83 and 84) allows this. In some cases the law requires ADC to provide this information. ADC may use details from this application and any future updates to form part of the public register. This duty is placed on ADC by The Childcare (Supply and Disclosure on Information) (England) Regulations 2007.