Informed Consent Form Dcsi Screening Unit Child-Related Employment Screening Page 5
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5Part D: Employment Information
This section is to be completed by the Requesting Officer
Name of Requesting Organisation:
The Applicant is a:
Paid or prospective employee ($62.20)
Student ($42.40)
Contractor ($62.20)
Volunteer ($42.40)
Where applicant is a prospective employee, on what date will they commence employment?
Please provide us with any relevant detail about the nature of the applicant’s role and prospective duties:
THIS FORM WILL BE RETURNED IF INSUFFICIENT DETAIL IS PROVIDED IN THIS SECTION.
DISCLAIMER: the Screening Unit makes no representation that the assessment process will identify or
mitigate all risk. A screening assessment is conducted at a point in time based on information disclosed to
the Screening Unit. There is always the possibility that a relevant event, including a criminal incident, may
occur after screening has been conducted.
Details of the Requesting Officer (must be an officer of the Requesting Organisation)
Tick if the Requesting Officer is also the Verifying Officer
Title:
Name:
ID Number:
Position:
Organisation:
Business Address:
Suburb/town:
State:
Postcode:
Telephone:
(W)
(M)
Email address:
Alternate contact:
Alternate contact email address:
Multiple Applications
Are you lodging forms for other types of screening with this application? If yes, please indicate by ticking the relevant box
for all applications and lodge at the same time.
Child-related
Vulnerable person-
Aged Care Sector
General employment
employment screening
related employment
employment screening
probity check
screening
C5 | DCSI Screening Unit screening@dcsi.sa.gov.au 1300 321 592
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