National Criminal History Record Check (NCHRC) Application Consent to Obtain Personal Information - December 2011

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1 Natinal Criminal Histry Recrd Check (NCHRC) Applicatin Cnsent t Obtain Persnal Infrmatin - December 2011 University/Agency Name: Curse r Psitin Title: Applicant details: (Applicant t print all details) Surname: (Current Legal Surname) Given names: (In full) Maiden name: (If different t Surname) Given names: (In full if different t abve) Any ther surnames: Include Deed pll changes, alias s, previus married, etc Any ther names used / knwn by: (In full) Place f birth: (Twn r City/ State/ Cuntry) Date f birth: (DD/MM/YYYY) T O W N / S T A T E / C O U N T R Y D D / M M / Y Y Y Y Gender: Male: Female: Telephne n: Current residential address: Current pstal address: (Nt PO Bx Addresses) address) (nly if different t current residential Pst cde: Previus residential address ver last 5 years: ( Attach list if insufficient rm) Pst cde: Pstcde: Identificatin details: (nly the items listed if applicable) 1.Drivers/Firearms licence n: Perid f residence: / / t / / If actual dates are unavailable, apprximate dates will suffice State/Territry f issue: 2. Passprt number: Passprt cuntry: Natinal Criminal Histry Recrd Check - Cnsent t btain persnal infrmatin (Cmplete Exclusin) (BLOCK LETTERS and in black ink) I, hereby: Family name (Current) Given names (Current) 1. acknwledge that I have read the Spent Cnvictins Schemes sectin f the infrmatin sheet and understand that Spent Cnvictins legislatin (hwever described) in the Cmmnwealth and many States and Territries prtects spent cnvictins frm disclsure 2. understand that the psitin fr which I am being cnsidered is in a categry fr which the fllwing cmplete exclusin has been granted frm the applicatin f the Spent Cnvictins legislatin and that all spent cnvictins and findings f guilt recrded r pending relating t me will be released 3. have fully cmpleted this Frm, and the persnal infrmatin I have prvided in it relates t me, cntains my full name and all names previusly used by me, and is crrect 4. cnsent t Department f Health disclsing persnal infrmatin abut me frm this Frm t the CrimTrac Agency and the Australian plice services 5. cnsent t: (i) the CrimTrac Agency disclsing persnal infrmatin abut me t the Australian plice services (ii) the Australian plice services disclsing t the CrimTrac Agency, frm their recrds, details f cnvictins and utstanding charges, including findings f guilt r the acceptance f a plea f guilty by a curt, that can be disclsed in accrdance with the laws f the Cmmnwealth, States and Territries and, in the absence f any laws gverning the disclsure f this infrmatin, disclsing in accrdance with the plicies f the plice service cncerned (iii) the CrimTrac Agency prviding the infrmatin disclsed by the Australian plice services t Department f Health in accrdance with the laws f the Cmmnwealth, and 6. acknwledge that any infrmatin prvided by me n this Frm, r by the Australian plice services, may be taken int accunt by Department f Health in assessing my suitability fr the psitin f... fr which I am applying. Applicant signature: Date: D D / M M / Y Y Y Y Nte: The infrmatin yu prvide in this Frm, and which the CrimTrac Agency prvides t the Department n receipt f the frm, will be used nly fr the purpse stated abve unless statutry bligatins require therwise. 1

2 Identificatin Guide Acceptable Identificatin Fr The Prvisin f Service Within The Department f Health t be retained by applicant Evidence f identity Befre undertaking a NCHRC the Department must be in n dubt as t the identity f the applicant. Yu must submit phtcpies f dcumentary evidence f Certified Identificatin t the value f 100 pints tgether with the Criminal Recrd Screening Cnsent Frm (PAGE 1), prir t cmmencing emplyment within the Department. Where yu have changed yur name (i.e. thrugh marriage r deed pll) evidence must be prduced t supprt this. TYPES OF IDENTIFICATION Only ne item frm each bx is permitted t make up the 100 pint ttal - Birth certificate (riginal, certified cpy r extract) - Current passprt/internatinal travel dcument - Citizenship certificate (riginal r certified cpy) POINTS Use nly ONE f the abve Driver s licence/permit - Public Service ID card - Scial security benefits card - Tertiary student ID card Name, signature and phtgraph where applicable must be supplied. Use nly ONE f the abve. 40 A signed written reference frm: - A financial bdy - An acceptable referee The reference must cnfirm a twelve mnth assciatin with the recmmended applicant. Use nly ONE f the abve. 40 Medicare Card 25 Membership card - Unin r trade/prfessinal bdies 25 Recent arrival in Australia (less than six weeks) - Passprt (resident) 100 Islated Area Abrigine - A written statement f cnfirmatin f identificatin signed by tw acceptable referees. 100 NOTE: Certified cpies f the abve dcuments must be prvided. Dcuments can be certified by anyne that has knwn yu fr 12 mnths r mre that is nt related by birth r marriage, r alternatively dcuments can be certified by taking the riginal s and cpes int a Pharmacy, Plice Statin r Pst Office. There are tw ptins fr btaining a Department f Health Screening: If yu have a valid Natinal Plice Certificate (NPC) (with date f issue being within the past 12 mnths), fill ut page ne f the Cnsent Frm and pst it in with a certified cpy f yur NPC (this has n cst) Cmplete page ne f the Cnsent frm and pst it in alng with 100 pints f certified ID and payment f $

3 Infrmatin regarding WA Health Criminal Recrd Screening Plicy t be retained by applicant Abut the plicy WA Health has a duty f care t take all reasnable steps t prtect clients frm harm and is cmmitted t the preventin f crime against all clients receiving health services frm: Gvernment agencies; Nn-gvernment rganisatins funded by Gvernment; Vlunteer rganisatins invlved in Gvernment services; and Private cntactrs prviding services t Gvernment. T assist in the prtectin f clients, the screening f criminal recrds will apply t all prspective: Emplyees (full/part time, temprary, casual, sessinal, cntract (includes redeplyees)); Independent cntractrs (includes all visiting practitiners) and their emplyees; Private agency staff; Students n placement (excludes schl children n wrk experience); Vlunteers; and Persns engaged in any ther capacity (e.g. Adults n wrk experience, chaplains, academics) N persn in the abve categries will be allwed t wrk r prvide services withut a criminal histry recrd check. Previus criminal cnvictins r pending charges will nt necessarily preclude emplyment r invlvement in the prvisin f services. Yur persnal infrmatin will be held in the strictest cnfidence and will nt be used by WA Health fr any purpse ther than t determine yur suitability fr the prvisin f services t clients f WA Health. Only the Criminal Recrd Screening Office in Perth will hld utcmes f the criminal histry recrd checking prcess. Yur infrmatin will nt be disclsed by WA Health except as prvided fr in the Criminal Recrds Screening Plicy r as required by law (e.g. Freedm f Infrmatin Act). Serius Cnvictin The definitin f a serius cnvictin under the Spent Cnvictins Act 1988 (WA) means a cnvictin in respect f which the sentence impsed is (a) imprisnment fr mre than ne year r fr an indeterminate perid; r(b) a fine f $15,000 r mre. Other than in exceptinal circumstances, a persn wh has been cnvicted f a serius sexual ffence(s) will nt be emplyed r invlved in the prvisin f services t clients. Other serius ffences (e.g. serius ffences invlving threat r injury t anther persn and serius drug ffences) relevant t the duties f the psitin may render a persn unsuitable fr emplyment and/r prvisin f services t clients. This will be determined by the Crdinatr, Criminal Recrd Screening in cnjunctin with ther relevant parties. If a persn has been cnvicted f a serius ffence, he r she may be precluded frm emplyment r invlvement in the prvisin f client services within a WA Health site. There is a prescribed Grievance Reslutin Mechanism, which can be fund in the Operatinal Guidelines. This prcess shuld be fllwed if yu wish fr a decisin regarding yur criminal recrd screening t be independently reviewed. Criminal Histry Recrd Check Criminal histry recrd checks are an integral part f the assessment f yur suitability. Infrmatin extracted frm this Frm will be frwarded t the CrimTrac Agency and ther Australian plice services 1 fr checking actin. By signing the Frm yu are prviding yur cnsent t these agencies: a) disclsing criminal histry infrmatin that pertains t yu frm their wn recrds t WA Health; and/r b) accessing their recrds t btain criminal histry infrmatin that in turn will be disclsed t WA Health. Such criminal histry infrmatin may include utstanding charges, and criminal cnvictins/findings f guilt recrded against yu that may be disclsed accrding t the laws f the relevant jurisdictin and, in the absence f any laws gverning the release f that infrmatin, accrding t the relevant jurisdictin's infrmatin release plicy. It is usual practice fr an applicant s persnal infrmatin t be disclsed t Australian plice services fr them t use fr their respective law enfrcement purpses including the investigatin f any utstanding criminal ffences. 1 Australian Federal Plice, New Suth Wales Plice Frce, Victria Plice, Queensland Plice Service, Suth Australia Plice, Western Australia Plice, Tasmania Plice, Nrthern Territry Plice Frce. 3

4 Restrictins n the release f criminal histry infrmatin As frm 31 May 2005, WA Health was granted exemptin t the Spent Cnvictins Act 1988 (WA) relating t cnvictins/findings f guilt f ALL Western Australian ffences. Therefre, in accrdance with that Act, ALL spent cnvictins/findings f guilt fr Western Australian ffences will be released. NO CRIMINAL HISTORY INFORMATION WILL BE FORWARDED TO THE AGENCY OR UNIVERSITY Nte: A Criminal Recrd Screening Check prcessed thrugh WA Health can nly be used fr emplyment purpses and prviding services within WA Health. It must nt be used fr any ther purpse. IT IS NOT A WORKING WITH CHILDREN CHECK OR AN AGED CARE CLEARANCE. Spent Cnvictins Schemes Western Australia Under the prvisins f Sectin 7(1) f the Spent Cnvictins Act 1988 (WA) nly lesser cnvictins can be spent by the WA Plice Service, after a time perid f 10 years plus any term f imprisnment that may have been impsed. A lesser cnvictin is ne fr which imprisnment fr 12 mnths r less, r a fine f less than $15,000 was impsed. All ther cnvictins, such as serius cnvictins applicable under Sectin 6 f the Act can nly be spent by applying t the District Curt. At the time f sentencing, the Curt may make a spent cnvictin rder under the Sentencing Act 1995 (WA) that the cnvictin is a spent cnvictin fr the purpses f the Spent Cnvictins Act 1988 (WA). Schedule 3 Clause 1(7) f the Spent Cnvictins Act 1988 (WA) gives WA Health an exemptin t access all spent cnvictins fr the purpse f emplyment/secndment by WA Health under the: a) Health Act 1911 b) Hspitals and Health Services Act 1927 c) Mental Health Act 1996 d) Alchl and Drug Authrity Act 1974; and placement as a student undertaking a practicum r in an unpaid capacity within WA Health. Other Australian plice services Where a criminal histry recrd with anther Australian plice service has been btained, any relevant legislatin (and/r release plicy) affecting that plice service will be applied befre that recrd is released. Under varius pieces f Cmmnwealth, State and Territry legislatin a persn has the right, in particular circumstances r fr a particular purpse, t nt disclse certain cnvictins/findings f guilt ver a certain age. Such cnvictins (widely referred t as spent r rehabilitated cnvictins) will nt be released unless the recrds check is fr the applicant s persnal infrmatin nly and prvided that this is in accrdance with relevant legislatin (and/r release plicy). Please cntact individual plice services directly fr further infrmatin abut their release plicies and any legislatin that affects them. Criminal Recrds Screening Office WA Health has an established Criminal Recrds Screening Office. The fficers wh wrk in this area are highly experienced and are bund by strict cnfidentiality prvisins. The Office will prcess yur Criminal Recrd Screening Check and frward yur name t CrimTrac. The prcess can take between three (3) and fifteen (15) wrking days, hwever sme delays can ccur. Cnsent Frm This Frm is used by WA Health as part f the assessment prcess t determine whether a persn is suitable fr emplyment r ther engagement fr wrk within WA Health. Unless statutry bligatins require therwise, the infrmatin prvided n this Frm will nt be used withut yur prir cnsent fr any purpse ther than in relatin t the assessment f yur suitability. Yu may be required t cmplete anther cnsent frm in the future in relatin t emplyment in ther psitins within WA Health. The Criminal Recrds Screening Office must have a signed Cnsent Frm befre a Criminal Recrd Screening Check is cnducted. Yur screening check will be unnecessarily delayed if yur writing is illegible r if yu have mitted infrmatin. Delays can mean that yu are unable t cmmence yur placement. Prvisin f false r misleading infrmatin Yu are asked t certify that the persnal infrmatin yu have prvided n this Frm is crrect. If it is subsequently discvered, fr example as a result f a check f plice recrds, that yu have prvided false r misleading infrmatin, yu may be assessed as unsuitable. Yu shuld nte that the existence f a recrd des nt mean that yu will be assessed autmatically as being unsuitable. Each case will be assessed n its merit, s it is in yur interests t prvide full and cncise details in the Frm. 4

5 Cmpulsry 100 pint identificatin check Dcumentary evidence f acceptable identificatin is t be attached and submitted by all persns prir t a Criminal Recrd Screening Check being undertaken fr the emplyment r the prvisin f services within WA Health. In rder t undertake a Criminal Recrd Screening Check, yu need smene else t verify that they have sighted the riginal dcumentary evidence f identificatin. This persn; - Must NOT be related t yu by birth r marriage; - Must have knwn yu fr at least ne year (12 mnths); - Must be cntactable by telephne during nrmal wrking hurs; - Must sight dcumentary evidence f identificatin t the value f 100 pints; - Must ensure that phtcpies f dcumentary evidence used are taken and signed ff as the riginal being sighted. Fee The fee payable fr yur Criminal Recrd Screening Check is $33.00 (GST inc.) If yu have undergne an Australian Federal Plice (AFP) Check and/r btained a Natinal Plice Certificate (NPC) within the last 12 mnths and there are n cnvictins listed that cntravene WA Health s Criminal Recrd Screening plicy, there is NO FEE prvided supprting dcuments are attached t the Cnsent Frm; i.e. a certified cpy f the AFP clearance r the NPC. A clearance card will then be issued frm the date that screening was cmpleted. Clearance Card Once the Criminal Recrds Screening Office receives the results f yur Criminal Recrd Screening Check, and there is n further actin t cmplete and yu are cleared in accrdance t WA Health s Criminal Recrd Screening Plicy, a clearance card will be prduced fr yu. This card will be frwarded t the current address prvided n the Cnsent Frm, r the relevant Agency. YOU MUST CARRY THIS CARD WITH YOU AT ALL TIMES WHEN WORKING WITHIN A WA HEALTH SITE AS EVIDENCE THAT YOU HAVE BEEN SCREENED. YOU ARE RESPONSIBLE FOR YOUR CARD. REPLACEMENT CARDS WILL COST $5.50. Where t send yur cmpleted Cnsent Frm Yur cmpleted Cnsent Frm tgether with the $33.00 and 100 pint ID remittance (please staple yur cheque/mney rder t the Cnsent Frm made payable t WA Health), shuld be frwarded t: The Criminal Recrds Screening Office WA Health Lcked Bag 60 PERTH BUSINESS CENTRE WA 6849 The Criminal Recrd Screening Office can be cntacted via: Phne: r CR.Screening@health.wa.gv.au At the cmpletin f the screening prcess, the Cnsent Frm tgether with a clearance card will be returned. Checklist Befre yu frward yur Cnsent Frm t the Criminal Recrd Screening Office fr prcessing please check dt pints belw t ensure all relevant dcumentatin is attached. Any uncmpleted Cnsent Frms will be returned. Cnsent frm cmpleted and signed (page 1) Certified cpies f 100 pints f ID and/r a certified cpy f yur Natinal Plice Certificate attached Crrect cheque/mney rder made payable t WA Health if applicable FOR SECURITY REASONS YOUR CONSENT FORM AND REMITTANCE WILL NOT BE ACCEPTED PERSONALLY AT WA HEALTH. THIS IS NOT A WORKING WITH CHILDREN CHECK OR AN AGED CARE 5

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