National Criminal Record Check Consent Papers Page 4

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Applicant Declaration and Employment Screening Consent Form for Child Related Employment (page 2)
DECLARATION
I am the applicant named in this form. All information in this form, and identification documents provided for this application, are true
and correct. I understand that if I have provided false or misleading information it may result in a decision not to employ me, or, if
already employed, may lead to my dismissal.
I have not omitted any names or aliases that I use or used in the past.
I have read and understood the contents of this form and the relevant information in the Working With Children Guidelines. I declare
that I am not a prohibited person under the Commission for Children and Young People Act 1998 and I understand that it is
an offence for a prohibited person to seek child-related employment.
I am aware that if considered for child-related employment with NSW Health, several checks will be undertaken to
ascertain my suitability, including checks directly related to child related employment and checks related to more general
suitability for employment in the public sector.
1. In relation to checking for general public sector employment national criminal record check for all charges which have not
been heard or finalised by the court and for all convictions vetted in accordance with the Criminal Records Act 1991 or, if
a Commonwealth offence, the Commonwealth Crimes Act 1914.
2. In relation to undertaking a Working With Children Check:
National criminal record check for charges and/or convictions (including spent convictions, convictions or charges that may
have not been heard or finalised by a court; or are proven but have not led to a conviction; or have been dismissed, withdrawn
or discharged by a court) for:
any sexual offence (including but not limited to, sexual assault, acts of indecency, child pornography, child prostitution
and carnal knowledge);
any child-related personal violence offence;
any assault, ill treatment or neglect of, or psychological harm to a child and any registrable offence;
punishable by imprisonment for 12 months or more.
In addition:
Check for relevant Apprehended Violence Orders taken out by a police officer or other public official for the protection of a
child or children; and
Check for relevant employment proceedings notified to the Commission for Children and Young People under the
Commission for Children and Young People Act 1998.
I understand that both checks will be undertaken by the Department of Health who is also an Approved Screening Agency.
CONSENT
I consent to these checks being conducted and consent to the Commission for Children and Young People or an Approved Screening
Agency obtaining any relevant record identified by these checks and any additional information relating to that record from sources
such as courts, police, prosecutors and past employers to enable a full and informed estimate of risk and/or Employment Risk
Assessment.
I consent to these sources disclosing information relating to the Working With Children Check relevant records to the
Commission for Children and Young People and/or Approved Screening Agency.
I acknowledge that:
1. In relation to a Working With Children Check:
the information obtained during the Working With Children Check, including this consent, may be collected and used by and/or
disclosed to the Commission for Children and Young People or an Approved Screening Agency for relevant purposes of the
Working With Children Check;
the Commission for Children and Young People and Approved Screening Agencies may share the information obtained during the
Working with Children Check for the purposes of the Working with Children Check;
the outcome of an estimate of risk will be provided to my prospective employer or their employer-related body;
the information provided may be referred to the Commission for Children and Young People and/or to NSW Police for law
enforcement purposes and for monitoring and auditing compliance with the procedures and standards for the Working With
Children Check in accordance with Section 36 (1)(f) of the Commission for Children and Young People Act 1998.
my relevant records under the Commission for Children and Young People Act 1998 will not be released to the Health agency
through which I am seeking employment;
2. In relation to a National Criminal Record Check:
the information provided will be used and/or disclosed by the Department of Health for the purposes of undertaking the check and
in this context, the information obtained as part of the National Criminal Record Check may be provided to the Health agency
through which I am seeking employment to ascertain my suitability;
3. Generally
any information obtained as part of this process may be used by Australian Police Services for law enforcement purposes,
including the investigation of any outstanding criminal offences.
Name: _________________________________________________________________________________________
Signature: ______________________________________________ Date: __________________________________
NOTE: This form is to be kept by the employer.
CGRM_WCC_HS 7.2 Last Updated March 2010

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