Informed Consent Form Dcsi Screening Unit Child-Related Employment Screening (Page 3 of 5) in pdf

Consent to Obtain Personal Information

, hereby:

First name (as on page 1)

Last name (as on page 1)

Declare that I am the applicant named on this form. All information and identification documents provided for this application are true and

correct.

Accept that providing false or misleading information may be an offence.

Certify that I have not omitted any names or aliases that I have used in the past;

Declare that I have read the contents of this Form, and the instructions provided on the How to Apply Section of the DCSI Screening Unit

website (paper copies available on request);

Consent to the DCSI Screening Unit collecting information in this Form to provide to the CrimTrac Agency and the Australian police

services;

Consent to:

the CrimTrac Agency disclosing personal information about me to the Australian police services;

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 the

Commonwealth, States and Territories and, in the absence of any laws governing the disclosure of this information, disclosing in

accordance with the policies of the police service concerned; and

the CrimTrac Agency providing the information disclosed by the Australian police agencies to the DCSI Screening Unit, in accordance

with the laws of the Commonwealth;

Consent to the DCSI Screening Unit obtaining ANY information from any police service, court, prosecuting authority or other authorised

agency and for the police service, courts, prosecuting authority or other authorised agency to disclose to the DCSI Screening Unit ANY

information, for the purposes of child-related employment screening;

Accept that this information obtained may include but is not limited to details of convictions and pending or non-conviction charges or

circumstances information relating to offences committed or allegedly committed by me, regardless of when and where the offence or

alleged offence occurred, and what the outcome may have been;

Consent to the DCSI Screening Unit:

accessing relevant information that may be held by the South Australian Government;

utilising the information provided by me on this Form, and information provided by the Australian police services, the CrimTrac

Agency, and the South Australian Government, to assess any risk I may pose in the event I am engaged to work or volunteer where

children are present;

providing details of that risk assessment, including any pertinent information, to the requesting organisation and any relevant

government supervisory agency; and

providing relevant criminal history information to the requesting organisation where permitted by the CrimTrac Agency to do so. In

relation to criminal history information obtained from other jurisdictions, the DCSI Screening Unit will only disclose information about

convictions or findings of guilt by a court.

10. Accept that the requesting organisation and, where applicable, the relevant government supervisory agency, shall make the final

determination as to my engagement in the position to which this application relates; and

11. Consent to the DCSI Screening Unit reassessing the risk assessment pertaining to me upon receipt of new or additional information, and

to the DCSI Screening Unit disclosing details of any reassessed risk assessment to my employer or any relevant government supervisory

agency;

12. Consent to my personal information being disclosed to police services for their respective law enforcement purposes, including the

investigation of any outstanding criminal offences;

13. Accept that Spent Convictions legislation (however described) in the Commonwealth and many States and Territories protects spent

convictions from disclosure, and 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; and

14. Discharge and agree to indemnify and hold harmless the State of South Australia, officers of the CrimTrac Agency, all Australian police

agencies and the Commonwealth, States and Territories of Australia, its servants and agents against all actions, suits, proceedings,

causes of actions, costs, claims and demands whatsoever which may be brought or made against it or them by me or by any body or

person by reason of or arising out of the release of any information obtained about me for the purposes of child-related employment

screening.

Signature of applicant

Date

Name and signature of parent/guardian

Date

(where applicant is under 18)

C3 | DCSI Screening Unit  screening@dcsi.sa.gov.au   1300 321 592

Informed Consent Form Dcsi Screening Unit Child-Related Employment Screening Page 3

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