PSD0001 Consent to Obtain Personal Information ... - Health Sciences

PSD0001Consent to Obtain Personal Information FormNational Criminal History Record Check (NCHRC) general informationTo be retained by applicantGeneral informationThis form is used by the Department of Corrective Services as part of the assessment process to determine whethera person is suitable for appointment, employment, provision of contracted services, other engagement or work withthe Department. Unless statutory obligations require otherwise, the information provided on this form will not be usedwithout your prior consent for any purpose other than in relation to the assessment of your suitability for a givenposition. You may be required to complete another consent form in the future in relation to employment in otherpositions within the Department.Criminal History Record CheckCriminal history record checks are an integral part of the assessment of your suitability. The Department may forwardinformation extracted from this form to the CrimTrac Agency and other Australian police services1 for checkingaction. By signing the form you are providing your consent to these agencies:a) disclosing criminal history information that pertains to you from their own records to the Department, and/orb) accessing their records to obtain criminal history information that in turn will be disclosed to the Department.Such criminal history information may include outstanding charges, and criminal convictions/findings of guilt recordedagainst you that may be disclosed according to the laws of the relevant jurisdiction and, in the absence of any lawsgoverning the release of that information, according to the relevant jurisdiction's information release policy.It is usual practice for an applicant’s personal information to be disclosed to Australian police services for them to usefor their respective law enforcement purposes including the investigation of any outstanding criminal offences.Spent Convictions SchemesA. Western AustraliaUnder the provisions of Section 7(1) of the Spent Convictions Act 1988 (WA) only lesser convictions can be spent bythe WA Police Service, after a time period of 10 years plus any term of imprisonment that may have been imposed. Alesser conviction is one for which imprisonment of 12 months or less, or a fine of less than $15,000 was imposed. Allother convictions, such as serious convictions applicable under s 6 of the Act can only be spent by applying to theDistrict Court. At the time of sentencing, the Court may make a spent conviction order under the Sentencing Act1995 (WA) that the conviction is a spent conviction for the purposes of the Spent Convictions Act 1988 (WA).Schedule 3 of the Act authorises the Department to access all spent convictions of WA offences for the purpose ofemployment into certain specified occupations eg a person authorised to exercise a power set out in the CourtSecurity and Custodial Services Act 1999 (WA) when (in the course of the person’s duties) assessing, reportingabout or classifying persons charged with or convicted of offences.Except under extenuating or mitigating circumstances, a person who has been convicted of a serious offence, asdefined in the above Act, would normally be disqualified from employment with the Department.B. Other Australian police servicesWhere a criminal history record with another Australian police service has been obtained, any relevant legislation(and/or release policy) affecting that police service will be applied before that record is released. Under variouspieces of Commonwealth, State and Territory legislation a person has the right, in particular circumstances or for aparticular purpose, to not disclose certain convictions/findings of guilt over a certain age.Such convictions (widely referred to as 'spent' or 'rehabilitated' convictions) will be released in accordance withrelevant legislation (and/or release policy). Please contact individual police services directly for further informationabout their release policies and any legislation that affects them.Provision of false or misleading informationYou are asked to certify that the personal information you have provided on this form is correct. If it is subsequentlydiscovered, for example as a result of a check of police records, that you have provided false or misleadinginformation, you may be assessed as unsuitable. You should note that the existence of a record does not mean thatyou will be automatically assessed as being unsuitable. Each case is assessed on its merits; hence it is in yourinterest to provide full and frank details on the form.1 Australian Federal Police, New South Wales Police Force, Victoria Police, Queensland Police Service, South Australia Police, Western AustraliaPolice, Tasmania Police, Northern Territory Police Force.Updated April 2010 Page 1 of 2

PSD0001Evidence of identityIdentification Guideto be retained by applicantBefore undertaking a NCHRC the Department must be in no doubt as to the identity of the applicant. To aid theDepartment in confirming your identity you will need to produce identification appropriate for the purpose, this can beascertained from the Applicant Identification Guide (refer this page).Departmental staff, a member of the selection panel or other face-to-face testing personnel will need to sight youroriginal identification documents or certified true copies thereof. No copies of your identification documents will betaken and you should not allow your documents to be taken away and/or copied.Use this guide to find out the type and amount of documentation that is required to establish your identity. ContractService Providers must have their identity established by their respective agency or the business area managerwhere they provide the service.When attending an interview you must provide documents (1), in one of the following combinations: Two (2) forms of identification from List 1or one (1) form of identification from List 1 and two (2) from List 2or three (3) forms of identification from List 2.List 1 List 2Any current passport (2)Australian drivers licence (2)Australian firearms licence (2)Birth certificateAustralian Defence Force, police service orGovernment photo identity cardCitizenship certificateDepartment of Immigration and Citizenship (DIAC)immigration papersDIAC certificate of evidence of residence status (withphoto)Expired Australian passport (not expired more than 5years)Credit or debit cardMedicare cardProof of age cardCentrelink or Department of Veterans Affairs cardSecurity guard / crowd control licenceTertiary education student ID cardTaxation assessment notice (3)Notes: Original documents or certified true copies must be sighted in one of the above combinations (1) In addition to identification documents presented, evidence of change of name is required if thename on any of the documents presented is different to the name of the applicant (A link betweenthe former name and current name must be established) (1) Only the numbers from passports, drivers and / or firearm licences are to be written on page 1 ofthe Consent to Obtain Personal Information Form (2) It is an offence under the Taxation Administration Act 2003 to ask for a Tax File Number as proof of(2) (3)Identity No copies of identification documents are to be made or retained by the Department or itsemployeesUpdated April 2010 Page 2 of 2

PSD0001Consent to Obtain Personal Information FormNational Criminal History Record Check (NCHRC) applicationApplicant details: (Applicant to print all details)Surname: (Current Legal Surname) Given names: (In full)Maiden name: (If different to Surname) Given names: (In full if different to above)Any other surnames: Include Deed poll changes, alias’s, previous married, etcAny other names used / known by: (In full)Place of birth: (Town or City/ State/ Country) Date of 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 YGender: Male: Female: Daytime telephone no:Current residential address:Current postal address: (only if different to current residential address)Post code: Post code:Permanent residential address over last five years: (If full list of previous addresses are unavailable details of town(s) and state(s)will suffice. Attach list if insufficient room)Period of residence: / / to / /If actual dates are unavailable, details of year of residence will sufficePostcode:Identification details: (only the items listed)-----------------------Do not make copies----------------------------------------------------1.Drivers/Firearms licence no:State/Territory of issue:2. Passport number: Passport country:National Criminal History Record CheckConsent to obtain personal information(Complete Exclusion)(BLOCK LETTERS and in black ink)I, ___________________________________________________________________________ hereby:Family name (Current) Given names (Current)1. acknowledge that I have read the Spent Convictions Schemes section of the information sheet and understand that Spent Convictionslegislation (however described) in the Commonwealth and many States and Territories protects “spent convictions” from disclosure2. understand that the position/entitlement for which I am being considered is in a category for which the following complete exclusion has beengranted from the application of the Spent Convictions legislation and that all “spent” convictions and findings of guilt recorded or pendingrelating to me will be released: Schedule 3 Sub-clause 1(1) items 12 & 13 of the Spent Convictions Act 1988 (WA)3. have fully completed this Form, and the personal information I have provided in it relates to me, contains my full name and all namespreviously used by me, and is correct4. consent to Department of Corrective Services disclosing personal information about me from this Form to the CrimTrac Agency and theAustralian police services5. consent to:(i) the CrimTrac Agency disclosing personal information about me to the Australian police services(ii) the Australian police services disclosing to the CrimTrac Agency, from their records, details of convictions and outstanding charges,including findings of guilt or the acceptance of a plea of guilty by a court, that can be disclosed in accordance with the laws of theCommonwealth, States and Territories and, in the absence of any laws governing the disclosure of this information, disclosing inaccordance with the policies of the police service concerned(iii) the CrimTrac Agency providing the information disclosed by the Australian police services to Department of Corrective Services inaccordance with the laws of the Commonwealth, and6. acknowledge that any information provided by me on this Form, or by the Australian police services, may be taken into account by Department ofCorrective Services in assessing my suitability for the position of ........................................................................................ for which I am applying.Applicant signature:Date:D D / M M / Y Y Y YNote: The information you provide in this Form, and which the CrimTrac Agency provides to the Department onreceipt of the form, will be used only for the purpose stated above unless statutory obligations require otherwise.Updated April 2010 Page 1 of 2

PSD0001Vacancy details: DCS Business Area, Contract Manager or panel chairperson to complete this section.DCS position no: DCS position title: Level:DCS division:DCS directorate:Has applicant had a break in service of 3 months or more? (Please circle)Yes No New DCS applicantRFT no:Service provider role: (External applicants only, please also Include DCS position and division)Agency name:Verification of applicant identification: DCS and service providersIdentification verified (please consult applicant Identification Guide) It is a contractual obligation that ID is verified and listed:Verified by: (Print Name)Position title:List ID checked, include document numbers: (form will be returned if not complete) Do not make copiesService providers please note:When completed, submit this form to the relevant section within the Department of Corrective Services (DCS) towhom you provide the service, or to the Contract Manager. Give the applicant the information page and Identification Guide to keep Send only the 2 pages of the form, fully completed, to DCS Do not take or make copies of an applicants identification documents Do not send consent forms direct to the screening officeIncomplete forms will not be processed.DCS Business Area or Contract Manager to complete this sectionForm checked by: (Print name) Position title:Signature:DCS contact person for notification:Date:D D / M M / Y Y Y YDCS email address for contact:DCS business area/contract manager please note:Once received, check the information is complete, fill in the section above and submit this form to the Screening Office. Send only the 2 pages of the form, fully completed, to the Screening Office.(not Recruitment and not Personnel Services)Facsimile: 08 9264 1764Scan and email:Internal mail:screening@correctiveservices.wa.gov.auLevel 8 Westralia SquareExternal mail: PO Box Z5124 Perth Adelaide Terrace WA 6831(Post Office preferred format)Incomplete forms will not be processed.Updated April 2010 Page 2 of 2