ITT Declaration Form

Please make sure that you staple the pages of this document together
UNIVERSITY OF EAST LONDON
Initial Teacher Training (ITT) Course:
Health Information and Enhanced Criminal Convictions Checks
Full name: HARDIK BANSAL
Address: 1ST FLOOR, B20 ,SANJAY NAGAR, SECTOR 2 ROHINI DELHI-110085
Contact Number: +91-8802845663
Email: bansalhardik1998@gmail.com
Intake Applied For: SEPTEMBER 2023
PREVIOUS NAME(S) AND ADDRESS(ES) FROM LAST FIVE YEARS

NAME ADDRESS DATE FROM-TO
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PLACE OF BIRTH (As per passport): JALANDHAR, PUNJAB INDIA
DATE OF BIRTH: JANUARY 01, 1998

Have you ever attended an ITT course before? NO
If yes please provide further details below including the institution, dates of attendance and reason for
leaving.
The Department for Education (DfE) states that students undertaking an Initial Teacher Training
course have undertaken:
1. An enhanced criminal conviction check via the DBS (Disclosure and Barring Service) or an equivalent
international body; and
2. A health check encompassing a self-declaration and statement from a GP.
GUIDANCE NOTES FOR ENHANCED CRIMINAL CONVICTION CHECKS DECLARATION FORM
Please read this carefully
1. Every candidate invited to attend for interview must complete this form whether they have a
previous conviction or not. Previous convictions include warnings, reprimands and some
driving offences.
2. For candidates who have previously been convicted of a criminal offence, or disclose a
pending court appearance or current charge:
2.1 Any details that you provide will be treated in the strictest confidence and will not
automatically exclude you from being considered for this or any course.
2.2 We may wish to ask you about any disclosures during your individual interview.
3. The amendments to the Rehabilitation of Offenders Act 1974 provide that certain spent
convictions and cautions are 'protected' and are not subject to disclosure to employers, and
cannot be taken into account. For details see DBS (Disclosure and Barring Service) website.
4. You must provide information on page 1 of Convictions within the armed services, outside the
United Kingdom.
Please note:
• Having a criminal conviction does not automatically bar you from entering an ITT course
but it does depend on the nature of the offence and when it occurred
• If anything later comes to light that is not declared now, this may lead to Fitness to
Practice proceedings and dismissal from the course
I have read and understood this:
Signed:
Name (printed): HARDIK BANSAL
Date: APRIL 05,2023

PART A: Criminal Information
ITT courses are exempt from certain provisions of the Rehabilitation of Offenders Act 1974 (as amended from time
to time) and information about all previous convictions, cautions, warnings or ongoing police matters must be
provided (there are some exceptions - for more information on this look at DBS website or consult the interview
team). A conviction does not automatically debar a student and the course will seek further information about the
circumstances to make an informed and considered judgement about a candidate's suitability in such instances.
Yes/No
Have you ever been disqualified from working with children by an order under Criminal Justice
and Courts Act 2000? No
Have you ever been Convicted of a Criminal Offence? No
Do you have a court appearance pending? No
Are you awaiting an outcome of any criminal offence? No
Have you ever received a fixed penalty notice? No
Have you ever received a caution or reprimand administered by the police? No
Have you ever been subject to a conditional caution? No
Have you ever been bound over to keep the peace for a period? No
Have you received an Anti-Social Behaviour Order (ASBO) made by any court? No
Have you ever been subject to an injunction made by a court in any proceedings? No
IF you have answered YES to any of the above questions, please supply the following details
Date Court Full Details of Offence Sentence
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PART B: Personal Health and Circumstances

We need to ensure students selected for the PGCE Primary, Secondary and PCET ITT courses have sufficient
stamina/resilience to manage both the rigours of the training and the challenges of professional life. Successful
completion of the PGCE Primary/Secondary/PCET requires full participation at university and whilst on teaching
placement.
The practice element of the PGCE Primary, Secondary, PCET may be undertaken with children or adults who may be
vulnerable, at risk, or whose capacity to manage their own affairs is temporarily or permanently impaired. Accordingly,
the course is required to ensure that all students are capable of enduring the demands of training and do not present any
threat to children, vulnerable adults or to themselves.
Please note that you are not required to make a declaration about health problems that do not impinge upon your
capacity to study or practice, or that in the normal course of your PGCE Primary/Secondary/PCET, would not present a risk
to others. If you do have health needs which are declared at the point of admission or during your course of studies, the
University will seek to ensure all reasonable adjustments are made in line with equality and diversity law. However, in
accordance with the requirements of the DfE, standards must be maintained to protect children/adults to ensure safe and
effective practice. The DfE asks that course providers for the PGCE Primary/Secondary ensure that applicants accepted are
in good physical and mental health. To this end, we at UEL, ask that candidates for our qualifying courses sign this
declaration of good health. We may also ask for medical verification in relation to this declaration.
In the case of medical conditions, with your consent, further information will be sought from your doctor, or a medical
consultant. We may also seek advice from our own medical and occupational health officers.
Full name: HARDIK BANSAL
Address: 1ST FLOOR, B20, SANJAY NAGAR, SECTOR 2, ROHINI, DELHI-110085
Contact Number: +91-8802845663
Doctor’s name: Dr. SARITA GUPTA
Doctor’s Address: HOUSE NO-51, POCKET-11, SECTOR-5, ROHINI, DELHI-110085
Doctor’s Contact Number: +91-9811815136

I declare that I am of good health: physically and mentally. I consider myself currently
able to withstand the academic and practice challenges of professional training with regards to the PGCE
Primary/Secondary, or PCET ITT course.
Please detail any conditions that may affect you while studying:
NO CONDITIONS
April 05, 2023

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Please make sure that you staple the pages of this document together

UNIVERSITY OF EAST LONDON

Initial Teacher Training (ITT) Course:

Health Information and Enhanced Criminal Convictions Checks

Full name: HARDIK BANSAL

Address: 1ST FLOOR, B20 ,SANJAY NAGAR, SECTOR 2 ROHINI DELHI-110085

Contact Number: +91-8802845663

Intake Applied For: SEPTEMBER 2023

PREVIOUS NAME(S) AND ADDRESS(ES) FROM LAST FIVE YEARS

PLACE OF BIRTH (As per passport): JALANDHAR, PUNJAB INDIA

DATE OF BIRTH: JANUARY 01, 1998

GUIDANCE NOTES FOR ENHANCED CRIMINAL CONVICTION CHECKS DECLARATION FORM

Please read this carefully

I have read and understood this:

Name (printed): HARDIK BANSAL

Date: APRIL 05,2023

Have you ever been Convicted of a Criminal Offence? No

Do you have a court appearance pending? No

Are you awaiting an outcome of any criminal offence? No

Have you ever received a fixed penalty notice? No

Have you ever received a caution or reprimand administered by the police? No

Have you ever been subject to a conditional caution? No

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Click here to enter text.

PART B: Personal Health and Circumstances

Full name: HARDIK BANSAL

Address: 1ST FLOOR, B20, SANJAY NAGAR, SECTOR 2, ROHINI, DELHI-110085

Contact Number: +91-8802845663

Doctor’s name: Dr. SARITA GUPTA

Doctor’s Address: HOUSE NO-51, POCKET-11, SECTOR-5, ROHINI, DELHI-110085

Doctor’s Contact Number: +91-9811815136

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