Background check consent form - Division of Local Government

NSW Department of Local GovernmentBackground checkconsent formAll fields must be completed. Please use block letters.Family nameGiven name/sPrevious names/aliasesI certify that the above information is accurate and understandthat if I have provided false or misleading information it mayresult in a decision not to employ me, or, if already employed,may lead to my dismissal.I am aware that if considered for employment, several checkingprocesses may be undertaken to ascertain my suitability. Ageneral criminal records check will be undertaken onrecommended applicants for all vacant positions.Date of birth/ / Male FemalePlace of birth (city, state, country)Residential addressSuburb/Town State PostcodeIdentifying document type (e.g. passport, birth certificate)Identifying document numberPosition applied forContact phone numberChild-related employmentIn addition to the general criminal records check, recommendedapplicants to child-related employment vacancies are subject to:1. A national criminal record check for charges and/orconvictions (including spent convictions) for:■ any sexual offence (including but not limited to, sexualassault, acts of indecency, child pornography, childprostitution and carnal knowledge)■ any child-related personal violence offence■ any assault, ill treatment or neglect of, or psychologicalharm to a child and■ any registrable offence punishable by imprisonment for12 months or more.I understand that this check includes convictions or charges that:■ may have not been heard or finalised by a court■ are proven but have not led to a conviction or■ have been dismissed, withdrawn or discharged by a court.Contact emailType of positionPaid employeeVolunteerContinued next page

NSW Department of the Arts, Sport and RecreationBackground checkconsent form2. A check for relevant Apprehended Violence Orders takenout by a police officer or other public official for theprotection of a child/ren and3. A check for relevant employment proceedings involvingan act of violence committed in the course of employmentand in the presence of children or reportable conduct.Reportable conduct means any sexual offence, or sexualmisconduct committed against, with or in the presenceof a child (including a child pornography offence) , anychild-related personal violence offence, or any assault,ill treatment or neglect of a child, or any behaviour thatcauses psychological harm to a child.I understand that a conviction for a serious sex offence(including, but not limited to, sexual assault, acts ofindecency, child pornography, child prostitution and carnalknowledge) or child-related personal violence offence(including but not limited to, intentionally wounding orcausing grievous bodily harm to a child) will automaticallyprohibit me from child-related employment. This includesa charge that is proven in court but does not proceed to aconviction. I am aware that if I am a “Registrable Person”under the Child Protection (Registrable Offenders)Act, 2000, I am prohibited from child-related employment.I consent to these checks being conducted and amaware that if any relevant record is identified, additionalinformation relating to that record may be sought by anApproved Screening Agency from sources such as courts,police, prosecutors and past employers to enable a full andinformed estimate of risk.DeclarationI acknowledge that:■ the above information and any information obtained duringthe Working With Children background check may becollected and used by/or disclosed to the Commissionfor Children and Young People or any Approved ScreeningAgency for the purposes of the Working With Children Check■ the Commission for Children and Young People or anyApproved Screening Agency may share the information obtainedduring the Working With Children background check with eachother to support further estimates of risk arising from additionalWorking With Children background checks■■■■the outcome of an estimate of risk conducted withinformation obtained through the Working with Children Checkby the Approved Screening Agency may be provided to mycurrent or prospective employers or an employer-related body(where applicable) only for background checking purposesdetails of my relevant records will not be released to mycurrent or prospective employersany information obtained as part of this process may beused by Australian Police Services for law enforcementpurposes, including the investigation of any outstandingcriminal offences andthe information provided may be referred to the Commissionfor Children and Young People and/or to NSW Police for lawenforcement purposes and for monitoring and auditingcompliance with the procedures and standards for theWorking With Children Check in accordance with Section36 (1) (f) of the Commission for Children and YoungPeople Act 1998.I consent to information obtained as part of this process beingkept on a departmental database for possible future employment.In addition, I consent to relevant personal details being kept on thisdatabase. I acknowledge that authorised personnel of the departmentcan access this information. This information will be used foremployment related purposes only.Name (block letters)SignatureDate/ /Note: This form is to be kept by the employer.Background check consent form – July 2008