National Diploma in Mental Health (Mental Health Support Work) 2016

National Diploma in Mental Health (Mental Health Support Work) 2016 For New Zealand Citizens & Permanent Residents Due to the Mandatory Review of Qualifications, this qualification will soon be replaced by the New Zealand Diploma in Health and Wellness (Mental Health), Level 5, and/or the New Zealand Diploma in Addiction Studies, Level 6, Details relating to these qualifications are not yet available. The National Diploma in Mental Health (Mental Health Support Work) programme offers you stimulating training, leading towards an advanced qualification as a Mental Health Support Worker. The National Diploma in Mental Health (Mental Health Support Work) programme is designed for people who have already developed or wish to develop a higher level of competence and more in-depth understanding of mental health support work than is covered by the Certificate level qualification in Mental Health and Addiction Support. These mental health support workers may have more seniority in the workplace, carry a higher level of responsibility, and engage in more complex relationships with consumers/tangata whai ora. They may also lead a team of mental health workers. Students are required to have completed either the National Certificate in Mental Health and Addiction Support or the pre-requisite unit standards from the National Certificate in Mental Health (Mental Health Support Work) in order to enrol in this diploma programme. EIT Hawke s Bay Students who have completed a course of study equivalent to these National Certificates may apply for RPL (recognition of prior learning) and should discuss this with the programme coordinator before enrolling. The remaining units for the National Diploma in Mental Health normally comprise a full-time 33 week programme. This programme has a large practicum component and on-line learning opportunities alongside six 3-day class-room block courses scheduled regularly though the year. This programme is open to all people who fulfil the entry criteria. Fees are to be paid by the individual student. The Ministry of Health offers a training grant to students in mental health placements/ workplaces to reimburse some of the course fees. In this application pack you will find information on the unit standards contained within the programme. You are welcome to make an appointment to discuss your study options with our staff and to view our facilities. Level 6 February 187 credits 33 weeks Full-time, part-time options are available Campus with On-line material and support $5,263 approximately. Depending on courses selected fees can vary. A $2,500.00 training grant to offset course costs is offered by the Ministry of Health to students in qualifying mental health placements or workplaces. The programme Coordinator can supply information about this grant and the application process. This is a guide only. All costs quoted include GST. Fees apply to NZ Citizens and New Zealand Permanent Residents only. Programme Contact: Hawke s Bay. Rita Smith Phone: 06 974 8000 ext 5079. Email: rsmith2@eit.ac.nz EASTERN INSTITUTE OF TECHNOLOGY 0800 22 55 348 eit.ac.nz Te Aho a Māui

Semester One Programme Starts Monday, 15 February 2016 Mid Semester Break 18 April - 29 April ANZAC Day Monday, 25 April Queen s Birthday Monday, 6 June Semester One Ends Friday, 24 June Mid Year Holidays 27 June - 15 July Semester Two Semester Two Starts Monday, 18 July Mid Semester Break 26 September - 7 October Term Four Starts Monday, 10 October HB Anniversary Day Friday, 21 October Labour Day Monday, 24 October Programme Ends Friday, 25 November 2016 $300 approximately for stationery and cost of personal travel to placement locations. Your career opportunities In the diverse mental health and addiction environment, support workers provide a variety of services to clients within a range of health and community settings. Possible jobs and career opportunities exist within: Community-based support services Day programmes Iwi health providers Mental health and addiction support services Peer support Residential support services Volunteer sector TOTAL NUMBER OF CREDITS The National Diploma consists of 187 credits. Students who have completed the National Certificate in Mental Health (Mental Health Support) will have already achieved 55 credits from the unit standards required for the Diploma. Students who have completed the National Certificate in Mental Health and Addiction Support will be able to cross-credit the equivalent credits. Please notify the programme coordinator to ensure the correct cross credits are recorded. In 20156 EIT will only be teaching the remaining 132 credits comprising the level 5 and level 6 unit standards required for the Diploma. ENTRY CRITERIA Academic Criteria Required NCEA Level 2 Information Session Recommend Police Check Required Health Declaration Required Yes Yes No IELTS 6.0 Min IELTS Band 5.5 Meet the NCEA Level 2, or provide evidence of achievement at an equivalent level. Or Attend an information session with a member of the academic staff and successful completion of the alternative academic entry test. Information session An information session is compulsory for those who do not meet the academic entry criteria and it is recommended for those who do meet the academic entry criteria. It will allow parties to exchange information about what the programme provides for students, and requires of students. Included will be discussion of possible career paths for the student, motivation, and physical and emotional requirements, and applicant s abilities, background, experiences and interests. Attendance of whanau members and/or other support people is encouraged.

Alternative academic entry assessment The alternative academic entry assessment will measure applicants literacy and numeracy ability to ensure that it is of a level to cope with the demands of the programme. Professional criteria All applicants are required to: Sign a declaration and a request for personal information held on the Police computer. If the declaration identifies any issue that may impact on the student s ability to complete the programme, the student can discuss these with the Programme Coordinator at an information session. EIT reserves the right to decline entry to the programme should an applicant s police record be such that they would be considered unsuitable for the type of work undertaken whilst on this programme or by graduates of this programme. The guidelines on which this decision will be based are the relevant professional association or industry requirements. English language entry requirement Applicants for whom English is not their first language must have an acceptable level of English language fluency prior to enrolment in the programme. This may be demonstrated in a variety of ways, including successful study of a programme in which English was the language of instruction, completion of a New Zealand Certificate in English Language (Level 3), approved scores on IELTS tests (6.0 Academic with no band score lower than 5.5), completion of accepted international equivalents, or completion of an EIT assessment. Entry with credit You may already have some knowledge or skills that can be recognized as part of your intended study. This may take a number of different forms including study while at high school, study at a private training establishment, workplace training, other tertiary study, life experiences or voluntary work. If you think you may qualify, you may want to apply for Cross Credit or Recognition of Prior Learning. Cross Credit is based on the equivalency of courses or qualifications. You would apply for Cross Credit if you have passed a very similar course at the same level. Recognition of Prior Learning (RPL) is based on the assessment of your current knowledge and skills. You would apply for RPL if you had gained the relevant knowledge and skills through life experiences and informal learning situations. You will be asked to provide details of anything that you would like considered as credit toward your intended programme of study, as part of your application. A student wishing to gain credits through RPL or Cross Credit for a course normally must have been accepted for the programme at the time of application for RPL. Enquiries about RPL and Cross Credit can be directed to Rita Smith, Programme Secretary, phone 06 974 8000, ext 5079. Class times 6 x 3-day blocks of face-to-face classroom based study are scheduled throughout the year. Students are required to complete at least two days per week in a workplace or practicum placement setting as well as self-directed study and on-line activities. Additional study days and tutorials will also be scheduled. Individual Study Hours The programme consists of a minimum of 132 credits (1320 learning hours). Assessments Assessments include essays, written reports, assignments, and practical demonstration of skills.. Academic Staff Our lecturers are highly trained professionals with particular areas of expertise in mental health. Staff maintains contact with other professionals in the health and education sectors. We value our partnership with students and aim to provide quality education in a supportive environment, encouraging personal growth and professional development. Name Chris Malcolm Programme Co-ordinator (06) 974 8000, ext 5840 cmalcolm@eit.ac.nz Diana Kirton Practicum Manager, School of Health and Sport Science (06) 974 8000, ext 5476 dkirton@eit.ac.nz Qualification MTh (Oxford), BTheol (Auck), BA (Victoria) BA Psychology, Otago

HOW TO ENROL STEP 1 STEP 2 STEP 3 Request an Application Pack. This includes detailed programme information, entry requirements, and an enrolment form. 0800 22 55 348 eit.ac.nz info@eit.ac.nz Complete and return the enrolment form and all supporting documents outlined in your Application Pack. You may be contacted and invited to an interview. You will receive an acceptance letter with programme information including your programme start date. Your acceptance letter may also include course selection forms, you need to complete and return them. You or your employer will receive an invoice. Organise payment of your fees. DISCLAIMER: There is a nationwide transition to new New Zealand qualifications at Levels 1-6. Information contained in this publication is correct at the time of printing, but may be subject to change. Whilst all reasonable efforts will be made to ensure listed programmes are offered and regulations are current, EIT reserves the right to change content, method of delivery, to withdraw any programme or course of study, or impose limitations on enrolment. Some programmes mentioned in this publication are subject to final approval and accreditation or sufficient enrolments being received. Fees for 2016 will be set by EIT Council by November 2015 and are subject to change. Check eit.ac.nz for the latest information or phone 0800 22 55 348.

WORLD CLASS A RATED LECTURERS EIT lecturers have the latest knowledge and research in their field of expertise, and are able to attract all-important research grants. For you, it means highly qualified academics who have the most up-to-date learning available. EIT is rated one of the top two institutes of technology and polytechnics in New Zealand for research excellence by the Tertiary Education Commission. This helps EIT secure funding through the Government s performance-based research fund. Government funding helps EIT continue to play a leading role in research in New Zealand. Our lecturers are in demand to work closely on research projects with universities, polytechnics, businesses and organisations at regional, national and international levels. They pass on their knowledge to you via their teaching. When you study at EIT, you will be at an institute that is highly rated for quality academic research. Student Finance STUDYLINK StudyLink is a service of the Ministry of Social Development. It administers Student Allowances and Student Loans as well as other forms of financial assistance for students. The StudyLink website provides tools, calculators and information to help students who are thinking about study to plan their finances and only borrow what they need. Use StudyLink s What You Can Get eligibility test to find out what you may be eligible for. STUDYLINK on 0800 88 99 00 or online at www.studylink.govt.nz

COURSE DESCRIPTIONS NB: Courses are offered subject to sufficient numbers applying. CORE / Compulsory Courses Course No Brief Description No. of Credits NZQA Level Semester Offered US 18547 US 19750 US 20043 US 22833 US 22834 US 22835 US 22836 US 22837 US 22838 US 22839 US 22840 US 22841 Support a mental health consumer/tangata whai ora in their management of alcohol and/or other drugs Provide support to families/whānau in mental health support work Support mental health consumers/tangata whai ora to access employment support services Support a consumer/tangata whai ora to achieve a recovery goal in mental health support work Analyze discrimination and implement an individual advocacy strategy in mental health support work Implement a strategy to respond to discrimination against consumers/tangata whai ora Analyze the application of ethical values for mental health support work Demonstrate an integrated theory for mental health support work Analyze legal structures and laws for mental health support work Analyze leadership and lead a group or team to achieve mental health support work objectives Critique and interpret a research project relevant to a mental health service user group Explain and apply knowledge of human development and health issues in mental health support work 12 6 Full year 15 6 Full year 12 6 Full year 15 6 Full year 9 6 Full year 15 6 Full year 6 6 Full year 15 6 Full year 6 5 Full year 6 5 Full year 9 5 Full year 12 6 Full year Practicum, Work Experience Practical work experience in mental health organizations forms an integral part of the Eastern Institute of Technology (EIT) Diploma in Mental Health (Mental Health Support Work). Students often regard their student placement as a key part of their learning experience.

NATIONAL DIPLOMA IN MENTAL HEALTH (MENTAL HEALTH SUPPORT WORK) 2016 DOCUMENTATION / FORMS Please Note The following documents need to be completed and returned with your application/enrolment to the School of Nursing Administration Office. Without these documents we are unable to proceed with your application Brief Personal Statement including Brief CV/Work History Consent to Disclosure of Information (Vetting Service Request and Consent Form) - Please ensure you provide two verified forms of ID, one of which must be photographic, for your vetting application

NATIONAL DIPLOMA IN MENTAL HEALTH (MENTAL HEALTH SUPPORT WORK) 2016 BRIEF PERSONAL STATEMENT Please also include a brief CV/Work History Name: 1. What do you believe are your personal strengths? 2. How would you describe your attributes as a friend, a family member, or as a member of your community? 3. Why are you interested in studying for a qualification in mental health support? 4. If you have worked/volunteered within this industry, please describe your experience and the number of hours involved. 5. As part of this programme you may have practical experiences with agencies or organisations that may require you to obtain a police vet of your personal information for any criminal convictions, criminal history, and details of fines and enforcements. Have you ever had a criminal conviction? Yes No A prior conviction may not necessarily exclude you from acceptance into the programme, but we may need to discuss it with you.

6. If you have any health or disability issues that may affect your ability to successfully complete this programme, that could affect your safety or those for whom you are providing care, please outline this:. 7. If you care for dependents or others and this may affect your ability to successfully complete the programme, please explain the nature of this and how it may affect your study. Sign: _ Date:

Vetting Service Request and Consent Form NZPVS CS 07/15 Section 1: Approved Agency to complete Name of Applicant to be vetted: Name of Approved Agency submitting vetting request: New Zealand Police Vet only Sections 1 & 2 to be completed New Zealand Police Vet & Australian National Police History Check Sections 1,2 & 3 to be completed APPLICANT S ROLE PURPOSE OF VET Employee Contractor/Consultant Volunteer Prosecution Vocational Training Licence/Registration Visa/Work Permit Other: (please specify here) Description of Applicant s role / licence / registration (e.g. caregiver; cleaner; taxi driver; teacher; etc): Student What group(s) will the applicant have contact with in their role for your agency? Children/Youth Elderly Other Vulnerable Adults Other: (please specify here) What is the applicant s primary role for your agency? Care & Protection (Children/Youth) Care & Protection (Elderly/Vulnerable Adults) Education Healthcare Other (please specify here) Is this request mandatory under the Vulnerable Children Act 2014 (VCA)? Yes( VCA Core Worker) Yes( VCA Non Core Worker) No (mandatory under other legislation/optional/standard Police Vet) Please note the NZ Police Vetting Service cannot provide any guidance as to whether requests are subject to the Vulnerable Children Act 2014. For information on this please see www.childrensactionplan.govt.nz. If this is a mandatory Vulnerable Children Act request, please specify the check reason below: New Children s Worker: Applicant is working for the first time in your organisation in a children s worker role. Existing Children s Worker: Applicant currently works for your organisation in a children s worker role. VCA Renewal: Subsequent vetting request for an existing children s worker, required once every three years. Application of the Criminal Records (Clean Slate) Act 2004: The NZ Police Vetting Service must comply with the Criminal Records (Clean Slate) Act 2004. Your answers to the above questions will assist us in determining what section of the Act applies to this vetting request. Section 16 (Clean Slate): Conviction history will not be released if applicant is eligible for clean slate. The role does not fit the criteria in section 19(3) of the Criminal Records (Clean Slate) Act, e.g. teacher, doctor/nurse, rest home carer. Section 19(3) (Exception): All criminal convictions will be released EVEN IF the applicant is eligible for clean slate. The role fits the criteria of one or more of the exceptions in section 19(3) of the Criminal Records (Clean Slate) Act e.g. it is a role predominantly involving the care and protection of, but not predominantly involving the delivery of education to, a child or young person (e.g. caregiver, nanny, foster/homestay parent, applicant for adoption) [section 19(3)(e)]. For information on the clean slate regime, see http://www.justice.govt.nz/services/criminal records/about the criminal records cleanslate act 2004. Page 1 of 7

Vetting Service Request and Consent Form NZPVS CS 07/15 Section 1 continued: EVIDENCE OF IDENTITY (ID) Approved Agency to complete for further information, see http://www.dia.govt.nz/resource material Evidence of Identity Standard Index I confirm that the identity of the applicant has been checked by [A] or [B] as follows: [A] I have (or my delegate has), OR, A Trusted Referee* has [B] sighted the ID documents below, and verified the photo against the applicant in person (mark box) and and Primary ID document (e.g. passport, original birth certificate, firearms licence, etc; see link above) Another form of ID (e.g. driver licence, 18+ card, Community Services Card, etc; see link above) One of the above must be photographic confirm comparison made and, if applicable Evidence of name change where names differ (e.g. marriage/civil union certificate, statutory declaration, etc * a Trusted etc) Referee must be over 16, and not be related, or a partner/spouse, or a co-resident of the applicant, and be either a person of standing in the community (e.g. registered professional, religious or community leader, Police employee) or registered with the Approved Agency. The Trusted Referee must: 1. sign [*a and trusted date referee the copies must of identity be over documents, 16, and and not endorse be related, each of or them a partner/spouse, appropriately e.g. or a co resident of applicant, "I have and sighted be either original a person version of this standing document" in the community (e.g. registered professional, religious or community I have sighted leader) the original registered version of this with document the Approved and I have Agency. compared The the Trusted photographic Referee image must with sign a copy (name of applicant) and confirm they apear to be the same person." of the photo ID and provide his or her name and contact details.] 2. provide her is his name and contact details Optional additional check by me (if appropriate) CHECKLIST A search of our records to verify uniqueness (especially for professional bodies) I have received an assertion of a RealMe verified identity limited to agencies who are able to use RealMe to verify identity for further information, see https://www.realme.govt.nz/ In making this request, I confirm that: I have complied and will comply with the Approved Agency Agreement (or existing Memorandum of Understanding) between NZ Police and the Approved Agency I represent; I am satisfied as to the correctness of the Applicant s identity (if applicable I confirm that Trusted Referee contact details have been provided); and I have obtained the Applicant s authorisation to submit this vetting request, as set out in section 2 of this form. Approved Agency Authorised Representative: Name: Date: Signed in electronic form: [mark box] OR Signature: Page 2 of 7

Vetting Service Request and Consent Form NZPVS CS 07/15 Name of Approved Agency submitting vetting request: Section 2: PERSONAL INFORMATION Applicant to complete and return to Approved Agency (the Approved Agency will submit the vetting request to NZ Police and receive the vetting result) Details (note: the name you are most commonly known by is your primary name) *Family name: (Primary) First name(s): (Primary) *Gender: (M) (F) (Other) *Date of birth: (dd/mm/yyyy) *Place of birth: (town/city/state) *Place of birth: (country) NZ Driver Licence number: (*where held for ID verification by NZ Police) If applicable, please include other names and mark them A, M, or P as appropriate: (A) alias or alternate name(s) (M) married name if not primary name (P) previous/maiden/name changed by deed poll or statutory declaration Family name: (A) (M) (P) First name(s): (A) (M) (P) Family name: (A) (M) (P) First name(s): (A) (M) (P) Family name: (A) (M) (P) First name(s): (A) (M) (P) Family name: (A) (M) (P) First name(s): (A) (M) (P) Permanent New Zealand Residential Address *Number/Street: Suburb: Post Code: *City/Town/ Rural District: *Period of Residence: *Denotes a mandatory field Page 3 of 7

Vetting Service Request and Consent Form NZPVS CS 07/15 Section 2: continued Applicant to complete and return to Approved Agency (the Approved Agency will submit the vetting request to NZ Police and receive the vetting result) CONSENT TO DISCLOSURE (for a New Zealand Police Vet) for further information, see http://www.police.govt.nz/advice/businesses and organisations/vetting I acknowledge and understand as follows: 1. The information about me that NZ Police may consider relevant to my application and release in vetting comprises any conviction history and, for certain agencies, infringement/demerit reports; and it may include any other information such as active charges and warrants to arrest, any information received or obtained by NZ Police, and any interaction I have had with NZ Police in any context (including family violence), even where I have not been charged, or charges are withdrawn, or I have been acquitted (not guilty) of a charge, or I have been discharged without conviction. 2. Any conviction history will be released in accordance with the Criminal Records (Clean Slate) Act 2004; this means that, if I am eligible for clean slate (e.g. no convictions for 7 years, never been to prison, no convictions for specified sexual offending, etc see section 7 of the Act): a. my criminal record of convictions will not be disclosed; but b. if the role for which I have applied is an exception to the clean slate scheme (e.g. predominantly involving care and protection of a child or young person), my criminal record of convictions will be disclosed. 3. Where relevant information is subject to statutory or Court ordered name suppression or prohibitions on disclosure, or other constraints on disclosure such as expectations of confidentiality or the protection of active criminal investigations or the safety of individuals, NZ Police may issue an alternative vetting result stating the existence of relevant non disclosable information, without details. 4. Where new information is obtained by NZ Police after the completion of my Police vet, NZ Police may disclose this information to the Approved Agency, and where appropriate to the Vulnerable Children Act Exemptions Administrator, if the information is considered relevant to the purpose of the Police vet. 5. The personal information I provide in this form is being collected for vetting purposes, and may also be used for the purpose of updating NZ Police records. 6. I may withdraw this consent, prior to Police s disclosure of the vetting result, by notifying the Approved Agency who will immediately notify NZ Police to cease the vetting process (any fee remains payable by the Approved Agency). 7. I am entitled to access the vetting result released to the Approved Agency and seek correction of Police information about me in accordance with the Privacy Act 1993 by making a request to the 'Approved Agency' in the first instance. 8. No later than twelve months after the release of the vetting result, the Approved Agency will securely dispose of this consent form and copies of identification documents, as well as the vetting result released by NZ Police, unless a longer retention period is required by legislation applying to the Approved Agency. 9. The information I have provided in this form relates to me and is correct. Applicant s Authorisation: I have read and understood the information above I authorise NZ Police to disclose any personal information it considers relevant to my application (as described above) to the Approved Agency making this request for the purpose of assessing my suitability. Signed in electronic form: [mark box] Date: OR Signature: Page 4 of 7

Vetting Service Request and Consent Form NZPVS CS 07/15 Section 3: Applicant to complete for Australian check (if required) ADDITIONAL PERSONAL INFORMATION (for Australian National Police History Check) Last Permanent Australian Residential Address Number/Street: Suburb: Post Code: City/Town/ Rural District: Period of Residence Australian Driver's Licence No: (if applicable) Australian Firearms Licence No: (if applicable) CONSENT TO DISCLOSURE State or Territory: If actual dates of residence are unavailable, year of residence will suffice Issued by: Issued by: General Information for an Australian National Police History Check GENERAL INFORMATION CrimTrac is collecting your personal information in this form in order to conduct a National Police History Check (NPHC) on you. Approved Agencies in New Zealand, named in section one, use the personal information collected on this form and the resulting NPHC as part of the assessment process to determine suitability for the position/entitlement/benefit which you are applying for. Unless statutory obligations require otherwise, the information provided on this form will not be used without your prior consent for any purpose other than in relation to the assessment of your suitability or to maintain the records of CrimTrac, Australian Police Agencies 1, or NZ Police. You will be required to complete another consent form for any future NPHC checks. NATIONAL POLICE HISTORY CHECK (NPHC) A NPHC is an integral part of the assessment of your suitability. Information on this form will be used by CrimTrac, and Australian Police Agencies for checking action; it will also be used to update records held about you by CrimTrac, Australian Police Agencies and NZ Police. Information released may include outstanding charges, warrant information and criminal convictions/findings/pleas of guilt recorded against you that may be disclosed according to the laws of the relevant jurisdiction and, in the absence of any laws governing the release of that information, according to the relevant jurisdiction information release policy. LIMITATIONS ON ACCURACY AND USE OF POLICE HISTORY INFORMATION While every care has been taken by CrimTrac to conduct a search of information held by Australian Police Agencies that relate to the applicant, the accuracy and quality of this NPHC depends on accurate identification of the Applicant (including aliases) according to the information provided in the Request and Consent Form and the comprehensiveness of police records. If the applicant does not complete the information requirements in this form the success and validity of the NPHC will be compromised. If for any reason you do not agree with the results of your NPHC, please notify the Approved Agency that you submitted the check through in the first instance, so that the NPHC dispute process can be initiated. The release of information by Australian Police Agencies is subject to relevant Spent Convictions, non-disclosure legislation or information release policies. 1 Australian Federal Police, ACT Policing, The New South Wales Police Force, Queensland Police Service, South Australia Police, Victoria Police, Western Australia Police, Northern Territory Police Force, Tasmania Police Service Page 5 of 7

Vetting Service Request and Consent Form NZPVS CS 07/15 General Information for an Australian National Police History Check, continued SPENT CONVICTIONS SCHEMES The aim of Spent Convictions legislation 2 is to prevent discrimination on the basis of certain previous convictions. Spent Convictions legislation limits the use and disclosure of older, less serious convictions and findings of guilt. Each Australian Police Agency will apply the relevant Spent Convictions legislation/information release policy prior to disclosure. The following links may be helpful in sourcing information on Spent Convictions in the Australian States & Territories but may not be relied upon. If further information or clarification is required please contact the individual Australian Police Agencies directly for further information about their release policies and any legislation that affects them. PROVISION OF INCOMPLETE, FALSE OR MISLEADING INFORMATION An Approved Agency or Applicant must take reasonable steps to ensure that the personal information collected, or disclosed is accurate, complete and up to date. You are asked to certify that the personal information you have provided on this form is correct. If it is subsequently discovered, for example as a result of a check of police records, that you have provided incomplete, false or misleading information, you may be assessed as unsuitable. It is a serious offence to provide false or misleading information in Australia. Commonwealth www.comlaw.gov.au New South Wales www.legislation.nsw.gov.au Queensland www.legislation.qld.gov.au South Australia www.legislation.sa.gov.au Victoria Police www.police.vic.gov.au Western Australia www.slp.wa.gov.au Northern Territory www.nt.gov.au/dcm/legislation/current.html Australian Capital Territory www.legislation.act.gov.au Tasmania www.thelaw.tas.gov.au 2 Applicable Spent Conviction legislation, as amended from time to time Page 6 of 7

Vetting Service Request and Consent Form NZPVS CS 07/15 Section 3: continued Applicant to complete for Australian check (if required) CONSENT TO DISCLOSURE (for Australian National Police History Check) I acknowledge, understand and consent as follows: 1. I have read the General Information in section 3 of this form and understand that information will be disclosed in accordance with applicable legislation and information release policies (including spent convictions legislation, however described) in the Commonwealth, States and Territories; 2. I understand that the position/entitlement for which I am being considered may be in a category for which exclusions from Spent Convictions legislation may apply; 3. I have fully completed this form, and the personal information I have provided in it relates to me, contains my full name and all names previously used by me, and is correct; 4. I acknowledge that the provision of false or misleading information is a serious offence; 5. I acknowledge that the Approved Agency named in Section 1 of this form is collecting information in this Form to provide to NZ Police to provide to CrimTrac (an Agency of the Commonwealth of Australia) and the Australian Police Agencies; 6. I consent to: a. CrimTrac using and disclosing personal information about me in this form to the Australian Police Agencies; b. the Australian Police Agencies disclosing to CrimTrac, from their records, Police History information that can be disclosed in accordance with the laws of the Commonwealth, States and Territories and in accordance with the relevant jurisdiction s information release policies; c. CrimTrac disclosing the information disclosed by the Australian Police Agencies to NZ Police, and d. NZ Police disclosing any criminal history information about me to the Approved Agency named in Section 1 of this form to assess my suitability in relation to my application; 7. I acknowledge that any information provided by me in this form relates specifically to the purpose identified in Section 1 of this form; 8. I acknowledge that any information provided by the Australian Police Agencies or CrimTrac relates specifically to the purpose identified in Section 1 above; 9. I acknowledge that personal information that I provide in this form may be disclosed to the Approved Agency named in Section 1 of this form (including contractors or related bodies corporate) located in New Zealand or overseas; and 10. I acknowledge that it is usual practice for an Applicant's personal information in this form to be disclosed to NZ Police and Australian Police Agencies for them to use for their respective law enforcement purposes including the investigation of any outstanding criminal offences. Note: The information provided in this form will be used only for the purpose stated above unless statutory obligations require otherwise. Applicant s Authorisation: I have read and understood the information above and consent accordingly Signed in electronic form: [mark box] OR Signature: Page 7 of 7