Informed Consent Form Dcsi Screening Unit Child-Related Employment Screening Page 2
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5Previous Addresses
Please record any previous permanent residential addresses over the last ten (10) years in the space provided
below, including overseas addresses. If there is insufficient space, please list them on a separate piece of paper
and attach it to this document.
If you have been a citizen or a permanent resident of a country/countries other than Australia since turning 18
years of age, you may be asked to provide further information or sign a statutory declaration about your criminal
history during this period.
Previous residential address:
Suburb/town:
State:
Postcode:
Period of residence:
From:
To:
Previous residential address:
Suburb/town:
State:
Postcode:
Period of residence:
From:
To:
Part B: Declaration and Informed Consent
1. Have you ever been dismissed or resigned from any employment or a volunteer role in response to or
Yes
following allegations of improper conduct relating to children?
No
2. Have you ever submitted an application for employment or a volunteer role involving contact with children
Yes
which was declined for disciplinary reasons or allegations of improper conduct?
No
3. Have you been (or are you currently) the subject of any professional disciplinary proceedings, or any
Yes
action that might lead to such proceedings in any jurisdiction? (not including criminal court proceedings).
No
4. Have you ever been (or are you currently) subject to any restrictions regarding your contact with children
Yes
(including removal of a child) in any employment, volunteer, or personal capacity?
No
5. Have you ever been found guilty of an offence committed in a country other than Australia, including an
Yes
offence for which no conviction was recorded?
No
6. Have you been named as the defendant in an Interim or Confirmed Intervention Order, Restraining
Yes
Order, Apprehended Violence Order or Domestic Violence Restraining Order, or equivalent, in any
No
jurisdiction?
7. Are you the subject of any criminal or traffic charges (not including parking or speeding infringements)
Yes
that are still to be determined or finalised?
No
8. Is your Driver’s Licence subject to any current restrictions?
Yes
No
Have you answered “yes” to any of the questions above?
If so, please submit a detailed summary of the circumstances surrounding the situation with your application. This should
include dates and, where applicable, the reasons for the decision, conditions of employment, offence type and date, the
court in which the matter was heard, and the status of any proceedings. Place this in a sealed envelope marked
“confidential” attach it to your completed Consent Form, and address it to the Manager, DCSI Screening Unit, GPO Box
292, Adelaide, SA, 5001.
C2 | DCSI Screening Unit screening@dcsi.sa.gov.au 1300 321 592
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