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Faculty of Health and Medical Sciences Pre-enrolment Requirements – MD, DMD and DPM
Congratulations on receiving an offer for a place in a Faculty of Health and Medical Sciences course. There are important compulsory Faculty health and legal screening requirements that you must now commence.
In order of priority:
1. Infection Control & MRSA Declaration 2. National Police Certificate (NPC) 3. WA Department of Health Criminal Record Screening (CRS) Clearance Card 4. First Aid Certificate
DEADLINES FOR SUBMISSION
You will not be able to enrol in your course until you have submitted your documents.
Direct Pathway students – 1 October 2018 Graduate offers – 7 January 2019
International students – Please see the note at the end of this document
Medical screening must commence as soon as you accept your offer. Your submission of the Infection Control Form (signed by both you and your GP) to the Faculty is required and must be received prior to the commencement of your course.
1 – Infection Control & MRSA Declaration
It is of the utmost importance that you meet the Faculty compulsory infection control requirements.
Details of the requirements, along with the Infection Control Form and other documents you need, are attached. Make this your first priority to ensure you are compliant, and, if treatment or vaccination is required, it is well underway before your course commences. Clearance can take time. For instance, if you have not been previously vaccinated for Hepatitis B, it can take at least 8 months to complete immunisations and confirm immunity.
The UWA Medical Centre on Crawley Campus is recommended. The Centre GPs understand the infection control requirements for students and provide assistance should you need to speak with an immunisation specialist. Make an appointment online or call +61 8 6488 2118.
If you visit another GP, you must submit all of your test results and vaccination records, in addition to your Infection Control Form and MRSA form.
Steps required
1. Make an appointment with UWA Medical Centre (recommended) as soon as possible after accepting your offer.
2. Take with you the Infection Control Form, MRSA form and list of the requirements. 3. MRSA: You must complete and submit the MRSA form (attached). Discuss with the GP if you have
worked or been a patient in a health care facility (e.g. GP clinic, hospital, nursing home setting) outside Western Australia in the past 12 months. If so, you are required to have an MRSA test (compulsory for all students, domestic and international). Nose and throat swabs must be taken, as well as skin lesion swabs if applicable.
4. Email the Infection Control & MRSA forms to [email protected]. Note: if your form has been completed by a GP outside UWA Medical Centre, you need to include copies of all blood test results and vaccination records.
5. You must let us know if you require further testing.
Important notes • UWA Medical Centre on Crawley Campus have GPs familiar with the infection control requirements. • All information supplied by the GP to the Pre-enrolment Officer will be handled confidentially. • MRSA screening swabs can be collected outside WA as long as you have not been in a health care
facility since taking the test. • It is your responsibility to follow up outstanding requirements and submit proof to the Faculty. • We will check non-compliance. You may be unable to proceed to the next level of your course if
you have not met the requirements. • You must keep a record of all your documents and results as we are unable to provide copies at a later
date.
2 – National Police Certificate (NPC)
All students will need to obtain a clear National Police Certificate. Applications can be made online (https://www.police.wa.gov.au/Police-Direct/National-Police-Certificates) or in person at participating Australia Post Outlets.
Steps required 1. Complete a National Police Certificate application form online or in person at Australia Post. 2. Submit a copy of the certificate to the Pre-enrolment Officer. Important notes • Certificates not issued by WA Police are accepted provided it has been issued by an organisation
accredited by the Australian Criminal Intelligence Commission (see list of accredited bodies at https://www.acic.gov.au/our-services/national-police-checking-service/find-out-more-information/accredited-bodies).
• National Police Certificates (and equivalent) must have been issued no earlier than 2018.
3 – WA Department of Health Criminal Record Screening (CRS) Clearance Card
As part of your course, you will undertake placements within WA Health sites and are required (under the Criminal Record Screening Guidelines) to consent to the screening of any criminal records. The application form is attached.
Steps required 1. Complete the WA Department of Health CRS Application and Informed Consent Form (see attached). 2. Submit the form and supporting documents to the WA Department of Health. Attach a certified copy of
your National Police Certificate to avoid paying the application fee.
3. Once you are cleared, you will be issued a Criminal Record Screening Clearance Card. 4. Email a scan of the front and back of your card to [email protected]. Important notes • WA Health Criminal Records Screening Unit address and contact details are on the application form. • If you have received your National Police Certificate (issued less than 12 months ago), attach a certified
copy to your CRS application, and you will not be required to pay the fee. • Read through the provided FAQs if you have questions about this process. • You must carry your card with you at all times when on a Department of Health site.
3 – First Aid (Provide First Aid) Certificate
You will be required to provide proof of successfully completing an Australian First Aid Course (accreditation number HLTAID0003 or HLTFA311A).
Steps required 1. Complete an approved Provide First Aid or Apply First Aid course: HLTAID003 or HLTFA311A. Courses
are available through providers such as Australian Red Cross, St John Ambulance and Surf Life Saving WA.
2. Submit proof of completion by emailing a copy of your certificate to [email protected]. Important notes • First Aid courses can vary; it's the accreditation number (HLTAID003 or HLTFA311A) that's important. • If you cannot complete the course by the deadline, submit evidence that you have booked and paid for
the course. Following completion of your course, email a copy of the Statement of Attainment as soon as it is available.
• Your Statement of Attainment is valid for three years, following which you will need to attend a refresher course.
SUBMITTING YOUR DOCUMENTS
You can submit your documents either via email (preferred), post or in person.
Documents emailed must be a clear, colour scan of the original document.
Send your documents to [email protected]
Enquiries may also be sent to this address.
Post or in person
Hard copy documents must be originals or correctly certified copies. Don’t forget to make a copy of all documents for your own records.
Mail your documents to, or visit us at, the following address:
Pre-enrolment Officer Faculty of Health and Medical Sciences (M353) The University of Western Australia Student Central, Ground Floor 35 Stirling Highway CRAWLEY WA 6009
INTERNATIONAL STUDENTS
If you are an international student currently overseas, we recommend that you wait until you have arrived in Australia before you start working through these requirements. Please book yourself into a GP appointment and first aid course as soon as possible, and email these booking details to [email protected].
Please contact us if you will be unable to complete the pre-enrolment requirements prior to the start of the semester, to avoid potential difficulties and delays in enrolling in your course.
Notes (Office use only): COMPLETED …… /…… /……
Compulsory Requirements Checklist: MD, DMD & DPM students
Name:
Student Number: Mobile:
Course Title: Use this checklist to make sure you have met the compulsory screening requirements. Attach it when submitting your documents. Keep a copy of all your documents and results.
1a. Infection Control Form Statement of Compliance (signed by GP and student)
Make an appointment as soon as possible to complete this requirement.
Note: The University Medical Centre GPs are familiar with the infection control requirements for students and are recommended. 1b. Blood test results and vaccination record
If your Infection Control Form was NOT completed by a GP from the University Medical Centre, you must submit a copy of your blood test results and vaccination record.
2. Methicillin-resistant Staphylococcus aureus (MRSA) declaration
You must advise us whether or not you have worked or been a patient in a health care facility (e.g. GP clinic, hospital or nursing home) outside WA in the past 12 months.
3. National Police Certificate (NPC)
Apply for an NPC from the WA Police website or visit a participating Australia Post outlet.
If you already have one, your NPC must have been issued on or after 1 January 2018. 4. Criminal Record Screening (CRS) Clearance Card
Apply for this check through the WA Department of Health. Once completed, a card is issued which you MUST carry at all times when on placement in a WA Health facility. Submit a copy of the card as evidence that you have been screened.
5. First Aid (Provide First Aid) Certificate
Certificate of completion of the HLTAID003 (Provide First Aid) or HLTFA311A (Apply First Aid) course available through providers such as Australian Red Cross, St John Ambulance and Surf Life Saving WA.
If you already have one, your certificate must have been issued on or after 1 March 2016.
Please submit before the deadline with notations of what is to follow.
Pre-enrolment Officer Faculty of Health and Medical Sciences (M353) The University of Western Australia 35 Stirling Highway CRAWLEY WA 6009 Email: [email protected]
INFECTION CONTROL FORM Statement of Compliance with the Faculty of Health and Medical Sciences
Infection Control Requirements To be completed by a registered medical practitioner.
Submit this form to the Pre-enrolment Officer as soon as possible.
I, Dr , report that the student’s immunisation status is now as follows:
1. Hepatitis B (HBsAb)
The student has HBsAb titres ≥10mIU/mL. Date of Blood Test
…..../…...../………. or a course of vaccinations has commenced:
1st dose (date) …..../…...../………
2nd dose (date) …..../…...../………
3rd dose (date) …..../…...../………
or a booster vaccination has been administered:
Booster dose (date) …..../…...../………
Note: A HBsAb titre must be performed (at least 4 weeks after final vaccination) and the result sent to the Pre-enrolment Officer
Hepatitis B (HBsAg) – For Dental Students Only:
Hepatitis B Antigen (HBsAg) blood test has been performed.
Result is Negative Result is Positive
Date of Blood Test
…..../…...../……….
2. Hepatitis C
Hepatitis C antibody blood test has been performed:
Result is Negative Result is Positive
Date of Blood Test
…..../…...../………. 3. HIV
HIV antibody blood test has been performed:
Result is Negative Result is Positive
Date of Blood Test
…..../…...../………. 4. Measles, Mumps, Rubella
The student has documented immunity to measles, mumps, and rubella:
Measles serology (date) ……../…….../…….. Mumps serology (date) ……../…...../………
Rubella serology (date) ……../……../………
or documented immunisation with 2 doses of MMR:
1st dose (date) …..../…...../………. 2nd dose (date) …..../…...../……….
or a booster dose of MMR vaccination was administered:
MMR given (date) …..../…...../………
Student name: DoB:
Pre-enrolment Officer Faculty of Health and Medical Sciences (M353) The University of Western Australia 35 Stirling Highway CRAWLEY WA 6009 Email: [email protected]
Last updated 25 June 2018
5. Varicella
The student has documented immunity to varicella. Date of Blood Test
……../…….../……..
or a varicella vaccination course has been administered:
1st dose (date) ……../…….../…….. 2nd dose (date) …..../…...../……….
6. Tuberculosis Quantiferon blood test or Tuberculin skin test has been performed:
Result is Negative Result is Positive
Date of QFN/TST
…..../…...../……….
7. Pertussis (Note: Do not undertake serological testing)
The student received a DTP course as a child and has received a pertussis booster within past 10 years.
or a pertussis booster vaccination was administered.
Date of booster
…..../…...../……….
Date of booster
…..../…...../……….
8. MRSA Screening (Note: Indicate if n/a)
MRSA testing is compulsory if the student has worked or been a patient in a GP clinic, hospital or nursing home outside WA within the past 12 months.
Result is Negative Result is Positive
Date of swabs (nose, throat and lesions required)
…..../…...../……….
9. Influenza
Yearly Influenza vaccination has been recommended.
Date recommended
…..../…...../……….
10. Hepatitis A (Not compulsory)
Vaccination is recommended for early childhood care workers and health care workers in remote Indigenous communities.
Vaccination commencement date (if applicable)
…..../…...../……….
GP Notes (additional information as required): GP Signature: Date:
GP Practice stamp:
Please provide a copy of all test results and vaccination records to the student for submitting with this form. (UWA Medical Centre staff are required to only provide positive HBsAg, Hep C, HIV, TB and MRSA results)
Student Declaration:
I understand the Faculty of Health and Medical Sciences infection control requirements and agree to submit this health screening information as a true and correct record of my compliance. I attach all of the test results if not completed by the University Medical Centre.
In addition, I agree to follow up outstanding vaccinations and provide evidence of completion including proof of my status regarding testing for blood borne diseases. I agree that if any test for a blood borne virus is positive, I will contact the Faculty Pre-enrolment Officer immediately for further discussion.
I will maintain my own records of compliance with these requirements, including copies of my test results and vaccination records.
Signature: Date:
Last updated 25 June 2018
Methicillin-resistant Staphylococcus aureus (MRSA) You must complete and submit this form (even if you answer “no’’).
Name:
Student Number: Mobile:
Course Title:
Have you worked or been a patient in a health care facility (e.g. GP clinic, hospital, nursing home) outside Western Australia in the last 12 months?
Yes
No (please submit this form even if this is your answer)
If yes, you must have an MRSA test. Nose and throat swabs are required, as well as skin lesion swabs where applicable. Note: nose, throat and skin lesion swabs can be collected outside WA as long as you have not been in a hospital setting since the testing. Signed: Dated: Submit this form with your Infection Control Form (and test result if applicable) to: [email protected]
or Pre-enrolment Officer Faculty of Health and Medical Sciences (M353) The University of Western Australia Student Central, Ground Floor 35 Stirling Highway, CRAWLEY WA 6009
Admissions, M353 Faculty of Health and Medical Sciences
A Letter to General Practitioners & Students
Infection Control Form Statement of Compliance with the Faculty of Health and Medical Sciences
As a condition of entry into professional courses co-ordinated by the UWA Faculty of Health and Medical Sciences (FHMS), commencing students must provide evidence of compliance with the Faculty Infection Control Requirements, which are based on the Australian Immunisation Handbook (10th edition, 2015) and WA Health Operational Directives 0394/12 Policy for Health Care Workers Known to be Infected with Blood-borne Viruses and 0388/12 Health Care Worker Immunisation Policy.
Please read the following detailed “Infection Control Requirements” documentation to ensure that you understand and comply with all requirements.
When completing the Infection Control Form, please note the following:
• Serological tests must have been performed in a NATA accredited laboratory.
• Please use the space provided on the form for further clarification (e.g. “inadequate measles titre, awaiting second dose of MMR” or “hepatitis B vaccination course not yet completed”.
Once complete, the student is required to sign the student declaration at the base of the form and submit the form, together with a copy of all test results and vaccination records, to the Faculty Pre-enrolment Officer prior to enrolment.
GPs are welcome to communicate directly with the Faculty Pre-enrolment Officer if required (e.g. if the student has an underlying medical condition which precludes the use of live vaccination).
The Faculty Pre-enrolment Officer must be advised of any student who is a carrier of a blood-borne virus. This is to ensure their training complies with the WA Health policy.
Information supplied to the Faculty will be handled confidentially. Thank you for your co-operation.
Pre-enrolment Officer Faculty of Health and Medical Sciences University of Western Australia email: [email protected] ph: +61 8 6488 4225
Admissions, M353 Faculty of Health and Medical Sciences
Infection Control Requirements for MD, DMD, DPM, Pharmacy and Social Work students
Students enrolled in the Doctor of Medicine (MD), Doctor of Dental Medicine (DMD), Doctor of Podiatric Medicine (DPM) and Master of Pharmacy (MPharm) courses in the Faculty of Health and Medical Sciences must comply with the specific requirements prior to undertaking clinical placements.
These guidelines are based on the Australian Immunisation Handbook (10th edition, 2015) and WA Health Operational Directives 0394/12 Policy for Health Care Workers Known to be Infected with Blood-borne Viruses and 0388/12 Health Care Worker Immunisation Policy.
Once a GP has determined that the student has complied with items 1 to 6 below, they are required to complete the Infection Control Form. This must be submitted to the Faculty of Health and Medical Sciences Pre-enrolment Officer prior to enrolment by the due date pre-specified. Failure to produce evidence of compliance with the requirements will preclude a student from commencing clinical placements.
The cost of testing and vaccination is met by the student.
The specific requirements are:
1. Hepatitis B
All students must have a blood sample taken to determine hepatitis B immunity. In addition, students enrolling in the Doctor of Dental Medicine (DMD) must have testing undertaken to exclude hepatitis B infection (HBsAg titre).
Evidence of immunity to hepatitis B virus (HBV) infection is required. Serological testing (a blood test) should be performed by a National Association of Testing Authorities (NATA) accredited laboratory. A hepatitis B surface antibody (HBsAb) titre of ≥10 mIU/mL is required.
If HBsAb titre is <10 mIU/mL and there is nil or incomplete documentation of prior vaccination, the student requires completion of a hepatitis B vaccination course prior to undergoing repeat serological testing.
Testing should be performed at least 4 weeks after final vaccination. A student may be undergoing vaccination at the time of enrolment but the Pre-enrolment Officer must be made aware of this. If there is no response to a full course of hepatitis B vaccination, the Pre-enrolment Officer must be contacted. Management will be in accordance with the Australian Immunisation Handbook.
Students who are known to have HBV infection must discuss this with the Pre-enrolment Officer prior to enrolment.
Students cannot enrol in the Doctor of Dental Medicine course if infected with a hepatitis B virus. Students in other courses may proceed under the guidance of the Infection Control Officer via the Pre-enrolment Officer.
Admissions, M353 Faculty of Health and Medical Sciences
2. Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) status (excludes Master of Pharmacy and Master of Social Work students)
All students (except Master of Pharmacy and Master of Social Work) must have a blood sample taken to determine their HIV and HCV status. Testing must be performed by a National Association of Testing Authorities (NATA) accredited laboratory.
This guideline is in accordance with current WA Health 0388/12 Health Care Worker Immunisation Policy which reference the Australian National Guidelines for the Management of Health Care Workers known to be infected with Blood-borne Viruses (published by the Australian Government Department of Health and Ageing, February 2012).
Students with hepatitis C or HIV infection planning to study courses other than dentistry will be allowed to enrol. Prior discussion must take place with the Pre-enrolment Officer and, during training, restrictions will be placed on the student regarding Exposure Prone Procedures (EPPs). Further details may be found within the Australian National Guidelines for the Management of Health Care Workers known to be infected with Blood-borne Viruses.
3. Measles, mumps, rubella and varicella All students must provide evidence of immunity to measles, mumps, rubella and varicella, as referred to in the The Australian Immunisation Handbook 3.3.7.
Acceptable evidence of immunity includes:
• Documented evidence of a prior full vaccination course (two vaccinations at least one month apart); or
• Presence of adequate antibodies on serological testing (measles IgG, mumps IgG, rubella IgG, and varicella IgG). Testing must be performed by a National Association of Testing Authorities (NATA) accredited laboratory.
Depending on the evidence produced, primary or booster vaccination may be required. This will be determined by the reviewing GP. Repeat serology following a completed vaccination course is not required.
4. Pertussis
All students must provide documentary evidence of up-to-date immunisation against pertussis (whooping cough).
Immunity against this infection cannot be determined by blood testing. Immunity is assumed if at least one documented dose of vaccine has been received within the last 10 years. If not previously vaccinated, or if vaccination records are incomplete, vaccination will be necessary.
5. Tuberculosis All students must have a Quantiferon-TB blood test or a Mantoux test (Tuberculin skin test) to determine evidence of past exposure to tuberculosis. If either of these tests are positive, further action is required. The student will be referred to the Anita Clayton Centre (previously Perth Chest Clinic) for review and a chest x-ray. A positive test does not preclude a student from enrolling. However, the case must be discussed with the Pre-enrolment Officer. This is in accordance with the WA Health Policy 6.3 Active Surveillance for Tuberculosis in Health Care Workers.
Admissions, M353 Faculty of Health and Medical Sciences
6. Methicillin-resistant Staphylococcus aureus (MRSA) Any student who has worked, volunteered or been a patient in a health care facility (e.g. GP clinic, hospital, nursing home setting) outside Western Australia in the 12 months prior to starting work in a WA hospital, must have nose, throat and skin lesion swabs taken to determine whether they are carriers of Methicillin-resistant Staphylococcus aureus (MRSA). Work in hospitals cannot be commenced until swabs are shown to be MRSA negative or until eradication treatment is prescribed by the Infection Control Officer (for those with positive results). See WA Health Operational Directive 0478/13 for more information.
7. Influenza
It is recommended that all students receive yearly influenza vaccinations.
8. Hepatitis A (not compulsory)
Although not compulsory, Doctor of Medicine students should consider vaccinating themselves against hepatitis A virus (HAV). The UWA Immunisation Guidelines and WA Health recommend vaccination by persons working in early childhood care and healthcare workers in remote Indigenous communities. It is recommended that students discuss this vaccination, including its costs, with their GP. More information regarding hepatitis A can be found in The Australian Immunisation Handbook 10th Edition, section 4.4 Hepatitis A.
Please provide a copy of all test results and vaccination records to the student for submitting to the UWA Health and Medical Sciences Admissions team.
Criminal Record Screening (CRS)
Frequently Asked Questions (FAQs) Q: How do I apply for a criminal record screening? (“White Card”) A: There are two options for obtaining a WA Health screening:
1. Submit valid National Police Certificate (NPC) to Health Support Services (HSS) (with date of issue being strictly within the past 12 months). There is no charge in this instance.
• State or Federal Police
o Complete the request form and post or email it to HSS with a certified copy of the NPC.
• Private company
o The check must include a child/vulnerable check and be an Australian screening (overseas screenings cannot be accepted)
o Complete the request form and post or email a certified copy to HSS
• Digital National Police Certificate (State or Federal Police Force)
o Email a copy to HSS (certification is not required)
o The copy must have a QR Code that can be scanned for a compliance check
2. Submit a Criminal Record Screening Request Form to Health Support Services (HSS)
• Complete the attached request form and post it to HSS along together with the minimum proof of
identity documents required as described on page 7 that have been certified and payment of $33.00 (cheque/money order made out to WA Health)
o There are currently no options for electronic payment
Q: How do I certify documents? A: Certification refers to a document copy that has been signed to confirm it is genuine.
• Document copies can be certified by someone that has known you for 12 months or more (who is not related by birth or marriage). This witness must be contactable by telephone during normal working hours.
• Alternatively document copies can be certified at a pharmacy, police station or post office.
Certification by a witness includes the following information written on the document copy:
• A statement of authenticity: e.g. 'Certified to be a true copy of the original seen by me'
• A signature and date of the witness
• A printed name under the signature.
• Additional information such as the occupation, address and telephone number of the witness.
Q: How long does a screening last? A: The WA Health Criminal Record Screening is valid for 3 years. If you present a National Police Certificate for clearance, the clearance date on your card will reflect the clearance date on that certificate. Note: The information you provide in this Form, and which the Australian Criminal Intelligence Commission (ACIC) provides to the Department on receipt of the form, will be used only for the purpose stated above unless statutory obligations require otherwise.
Q: What if I only need to renew my clearance? A: Renewal is no different from applying for a new screening. You need to submit a completed consent for or send through a certified copy of your National Police Certificate (paper or digital). Q: How do I pay for a screening? A: The fee payable for your Criminal Record Screening check is $33.00 (GST incl.) and needs to be paid by cheque or money order made out to WA Health. Unfortunately there is currently no facility for electronic payments. Q. Is there a charge if I have been screened elsewhere? A. If you hold a valid Australian Federal Police (AFP) check National Police Certificate (NPC) issued within the last 12 months there is no additional fee payable to WA Health. The clearance must have no convictions listed that contravene WA Health’s Criminal Record Screening policy, and must be provided as certified supporting documents attached to the consent form. Q. Will I be issued with a card if I have an external screening? Yes. A clearance card will be issued from HSS based on the issue date that the original screening was completed and will be valid for 3 years from that date. Q: How long until I receive my card? A: Clearance times are dependent on a response from the Australian Criminal Intelligence Commission (ACIC) and can vary due to many factors, including previous convictions. Your card will be issued promptly once the clearance confirmation has been received. Q. I have an international clearance. Can I use that instead? A. Overseas clearances cannot be accepted. The National Police Certificate (or equivalent) must relate to an Australian criminal screening. Q. How long before I need my card should I apply? A. You should apply at least 6 weeks prior to your placement or earlier if possible. As soon as you are aware you are going on clinical placement apply for CRS Q. Where do I send my request form or certified certificate? A. Forward your completed request form together with the $33.00 and 100 point ID to:
The Criminal Records Screening Office WA Health
Locked Bag 60 PERTH BUSINESS CENTRE WA 6849
The Criminal Record Screening Unit can also be contacted via phone and email:
Phone: 1300 367 894 Email: [email protected] Digital clearances can be emailed to: [email protected]. Include your surname in the email subject line and include your contact phone number and current postal address in the body of the email.
Note: The information you provide in this Form, and which the Australian Criminal Intelligence Commission (ACIC) provides to the Department on receipt of the form, will be used only for the purpose stated above unless statutory obligations require otherwise.
Section A – Personal information
A1. Please read this before answering the following questions.
You must disclose all names you have been known by throughout your life, including your primary name, name before marriage (maiden name), and other previous names and/or alias names.
With each additional name you provide, you must include your family name, first given names and other given names (if applicable).
Example: When Lucianne was born, she was given the first name Lucianne, second given name Jane and surname of Jones. When she was married, she changed her surname to Smith. Lucianne commonly uses the name Lucy when introducing herself in the community.
As such, Lucianne has four known names—her current name, pre-marriage name, the alias name she used before she got married and the alias name she uses now. Lucianne needs to provide all four names when completing this form, as follows:
Current name: Smith, Lucianne Jane Pre-marriage name: Jones, Lucianne Jane Alias name: Smith, Lucy Jane Alias name: Jones, Lucy Jane
Primary name Family name
First given name(s)
Other given name(s)
Previous known name (if applicable) Family name
First given name(s)
Other given name(s)
Name Type Maiden Alias Previous
Previous known name (if applicable) Family name
First given name(s)
Other given name(s)
Name Type Maiden Alias Previous
📎📎 If more room is required, please list on a separate sheet, sign and attach to this form.
Additional sheet attached? Yes No
A2. Please read this before answering the following question.
You must select the gender that best describes how you identify yourself within the community.
The ACIC’s processes are aligned with the Australian Government Guidelines on the Recognition of Sex and Gender. For more information, contact the ACIC directly on 02 6268 7900 or [email protected]
Your gender M (Male)
F (Female)
X (Indeterminate/intersex/unspecified)
A3. Please read this before answering the following questions.
If you cannot provide all these details, contact the accredited body or its legal entity customer.
Your date of birth
Your place of birth Suburb/town
State/territory
Country
/ /
1 Version 1.0 Australian Criminal Intelligence Commission
FOR OFFICIAL USE ONLY
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | APPLICATION AND INFORMED CONSENT FORM
A4. Please read this before answering the following questions.
Provide your current and previous residential addresses for the past five years.
If you cannot provide full details, provide as much information as possible. If you are unsure how to complete this section contact the accredited body or its legal entity customer.
Current residential address
Street address
Suburb/town
State/territory Postcode
Country
Dates residing at address:
From / /
Previous residential address 1
Street address
Suburb/town
State/territory Postcode
Country
Dates residing at address:
From / / To / /
Previous residential address 2
Street address
Suburb/town
State/territory Postcode
Country
Dates residing at address:
From / / To / /
Previous residential address 3
Street address
Suburb/town
State/territory Postcode
Country
Dates residing at address:
From / / To / /
📎📎 If more room is required, please list on a separate sheet, sign and attach to this form.
Additional sheet attached? Yes No
A5. Please read this before answering the following questions.
If you have an Australian drivers licence and/or an Australian firearms licence, you must provide the licence number and the state or territory that issued your licence.
If you have a foreign drivers licence and/or a firearm licence you must provide the licence number and the country that issued your licence.
If you have a passport, you must provide the passport number and the country that issued your passport.
Drivers licence number (if available)
Issued by (state/territory)
Firearm licence number (if available)
Issued by (state/territory)
Passport number (if available)
Issued by (country)
Section B – Purpose of the nationally coordinated criminal history check
The purpose for your nationally coordinated criminal history check helps determine what police information is disclosed on your result. B1 Please read this before answering the following question.
For question B1, provide the position title, occupation or entitlement for which you require this nationally coordinated criminal history check. Example: cleaner, case worker, Agency, student
Your position title, occupation or entitlement
B2 Please read this before answering the following question. For question B2, provide the proposed place of work relevant to the position, occupation or entitlement. Example: school, aged care facility, financial services office, domestic work sites, practicum placements, agency.
Your proposed place of work
2 Version 1.0
Australian Criminal Intelligence Commission
FOR OFFICIAL USE ONLY
NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | APPLICATION AND INFORMED CONSENT FORM B3. Please read this before answering the following question.
For question B3, indicate whether or not you will have contact with children and/or vulnerable groups as part of the role you are applying for. Direct or indirect contact means face-to-face contact, phone contact or any type of communication over the internet. Supervision means in the presence of an adult who is responsible for the safety or care of the child or vulnerable person.
Select the statement that best describes the role you are applying for:
No direct or indirect contact with children or vulnerable groups,
Direct or indirect contact with children or vulnerable groups, without supervision
Direct or indirect contact with children or vulnerable groups, with supervision
Section C – Informed consent
What is informed consent? Your informed consent is needed before an accredited body can request a nationally coordinated criminal history check on you. Your informed consent means you: • have read and understood the information provided in this
form about how your personal information and any police information relevant to you will be handled and disclosed
• provide your permission for the accredited body to request a nationally coordinated criminal history check on your behalf
• provide your permission for the accredited body to disclose your information to any organisation listed in C1 of this form.
How do I provide my informed consent? An important aspect of providing informed consent is that you understand what you are consenting to. It is important that you read the consent statements in question C2 and, where required, get clarification from the accredited body or its legal entity customer, to ensure complete understanding. You must then sign and date this form at C2, to give your informed consent. Important: Please read this information about question C1. The accredited body is required to complete question C1 before providing the form you.
Question C1 provides the details of the organisations to whom your personal and police information will be disclosed to.
In C2, you will provide your informed consent for your personal and police information to be disclosed to the ACIC, Australian police agencies, law enforcement agencies, and any organisations detailed in question C1.
C1 Organisations to whom the applicant’s personal and police information will be disclosed Accredited Body Accredited body (legal name)
Department of Health WA - Health Support Services
Address
Locked Bag 60 Perth Business Centre WA 6849
Preferred contact details
Phil Rigg
ABN
76887543297
C2. Please read this before answering the following question.
You must provide your name, read each statement carefully and then print your name, sign and date to provide your informed consent.
Applicant’s consent to submit a nationally coordinated criminal history check I, Family name
First given name(s)
Other given name(s)
1. acknowledge that I/the applicant understand the information on this form.
2. acknowledge that the accredited body named C1 is collecting information in this form to provide to the Australian Criminal Intelligence Commission (ACIC) and police agencies, for a nationally coordinated criminal history check to be conducted for the purpose outlined in Section B of this form.
3. have fully and accurately completed this form, and the personal information I/the applicant, have provided relates to me/the applicant, and contains the full name and all names previously used by me/the applicant.
4. acknowledge that withholding and/or providing misleading or false information on this form and in any supplied identity documents is a Commonwealth offence and may lead to prosecution under the Criminal Code Act 1995 (Cth).
5. acknowledge that personal information that I/the applicant provided in this form and on the supplied identity documents may be disclosed to the accredited body named in Section C of this form (including contractors, legal entity customers, related bodies or third parties named in C1 of this form in Australia or overseas, if applicable).
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6. acknowledge that any information sent by mail or electronically, in relation to this form, including identity documents, is sent at my/the applicant’s risk and I/the applicant, am aware of the consequences of sending information in these ways.
7. acknowledge that I/the applicant am aware that I/the applicant am providing consent for a national check to be conducted on all personal information provided in this form and provided in suppled identity documents.
8. understand and consent to police information relating to me/the applicant, being disclosed in accordance with the purpose identified in section B of this form, applicable legislation and information release policies (including spent convictions legislation described in Australian Government and state or territory legislation).
9. give consent to: a. the ACIC and police agencies using and disclosing
my/the applicant’s personal information that I/ the applicant, have provided in this form and personal information contained in my supplied identity documents to conduct a nationally coordinated criminal history check.
b. the ACIC disclosing the police information sourced from the police agencies to other approved bodies and the accredited body named in C1 of this form.
c. the accredited body named in C1 of this form disclosing to the legal entity customer, third parties and any permitted offshore transfer arrangements also detailed in C1, my/the applicant’s personal information and police information to assess my/the applicant’s suitability for the purpose identified in section B of this form.
10. acknowledge that it is usual practice for my/the applicant’s personal information and police information to be used by police agencies and the ACIC for law enforcement, including purposes set out in the Australian Crime Commission Act 2002 (Cth).
Applicant Print name
Signature
Date
/ /
Parent or legal guardian (where the applicant is under the age of 18) Print name
Signature
Date
/ /
Authorised agent (person responsible for the applicant, such as a legal representative) Print name
Signature
Date
/ /
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NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | APPLICATION AND INFORMED CONSENT FORM Section D - Office use only Accredited body or its legal entity customer declaration.
D1 What is the nationally coordinated criminal history check
category for this application? For example: Employ/probity/licence.
D2 What is the check type for this application? Standard
Volunteer
D2 The accredited body or its legal entity customer declares they have verified the link between the applicant’s personal details and identity documents, and is satisfied that they are correct.
Staff member Print name
Signature
Date
/ /
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Information about this form
Terms used in this form Nationally coordinated criminal history check
Describes both: the checking process undertaken by the ACIC and police, and the result received by the accredited body. Commonly known as a ‘police check’.
You/the applicant Individual seeking a nationally coordinated criminal history check.
Accredited body Organisation accredited with the ACIC and responsible for submitting your Application and informed consent form.
Australian Criminal Intelligence Commission (ACIC)
Australian Government agency responsible for facilitating access to nationally coordinated criminal history checks.
Legal entity customer Organisation the accredited body uses to collect your Application and informed consent form. This may be your employer, benefits provider or issuing body.
Third party Organisation the accredited body is required by law to disclose your personal information and police information to.
Personal information Information about you, including any information contained in your identity documents.
Police information Information released as part of a nationally coordinated criminal history check.
Who completes this form? Accredited body The accredited body or its legal entity customer pre-populates this form with information in these sections: How to submit this form, Contact details and question C1.
Applicant You are required to provide your personal details and informed consent to complete this form. You must also provide your identity documents, as detailed in Documents required. If you are less than 18 years of age, this form must be completed by your parent or legal guardian. You are completing this form to obtain a nationally coordinated criminal history check.
What is a nationally coordinated criminal history check? A nationally coordinated criminal history check is conducted with your informed consent to determine your suitability for a position of trust, specified field of endeavour or as required by legislation. A nationally coordinated criminal history check contains your personal information, and police information that is disclosable about you, according to the purpose of your check.
Privacy notice
How will my information be used? The ACIC and Australian police agencies The ACIC and Australian police agencies use the information on this form and the applicant’s identity documentation: • to disclose police information relating to you, to the
accredited body named in question C1. • to update records held about you • for law enforcement, including purposes set out in the
Australian Crime Commission Act 2002 (Cth)
Accredited body The accredited body or its legal entity customer uses the personal information collected in this form to request a nationally coordinated criminal history check and to assure itself of your identity.
The accredited body may have a legislative basis for the collection, use and disclosure of your personal information and police information to a third party. If applicable, third parties are listed in question C1. The ACIC recommends you seek more information about relevant legislation from the accredited body.
The accredited body or its legal entity customer must advise you if your personal information or police information will be transferred or supplied to a location outside Australia, known as the permitted offshore transfer arrangement. If this applies, the legal name and location of the overseas entity are listed in question C1. The ACIC recommends you seek more information from the accredited body listed in C1.
You can contact the accredited body for more information on how they handle your personal information using the contact details at the end of this section.
How is my national check result determined? Police information is disclosed in accordance with applicable legislation and information release policies of the Australian Government and state and territory governments.
These links may help you source information on spent convictions:
Australian Government www.legislation.gov.au Australian Capital Territory www.legislation.act.gov.au New South Wales www.legislation.nsw.gov.au Northern Territory www.legislation.nt.gov.au Queensland www.legislation.qld.gov.au South Australia www.legislation.sa.gov.au Tasmania www.thelaw.tas.gov.au Victoria www.police.vic.gov.au Western Australia www.slp.wa.gov.au
How do I dispute my result? If you do not agree with the results of your nationally coordinated criminal history check, contact the accredited body or, if applicable, its legal entity customer, using the contact details on page 3 and tell them you want to dispute the result. The accredited body or its legal entity customer accepts and escalates all disputes.
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NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | APPLICATION AND INFORMED CONSENT FORM Providing incomplete, false or misleading information You must take reasonable steps to ensure you provide accurate, complete and up-to-date personal information. Withholding and/or providing misleading, or false information on this form is a Commonwealth offence and you may be prosecuted under the Criminal Code Act 1995 (Cth).OW TO
If you become aware you have provided incorrect information you must contact the accredited body as soon as possible.
Documents required
Minimum identity requirements You must provide four documents with your completed form to confirm your identity: • one commencement document to confirm your birth in
Australia or arrival in Australia • one primary and two secondary documents to show the use
of your identity in the community.
The accredited body or its legal entity customer will use these documents to verify your identity against the personal information you have provided on this form. The personal information contained in the identity documents you provide will be used to conduct a nationally coordinated criminal history check, as you consent to in Section C.
The documentation you provide must include evidence of your full name and date of birth and a photograph of you. The commencement and primary documents provided must include a photo of you. If your commencement and primary documents do not include a photograph you must submit a passport-style photograph certified by a person listed in Schedule 2 of the Statutory Declarations Regulations 1993 (Cth).
Commencement documents (a) full Australian birth certificate (not an extract or birth card) (b) current Australian passport (not expired) (c) Australian Visa current at time of entry to Australia as resident
or tourist (d) ImmiCard issued by the Department of Immigration and
Border Protection that enables the cardholder to prove their visa and/or migration status and enroll in services
(e) certificate of identity issued by the Department of Foreign Affairs and Trade to refugees and non-Australian citizens for entry to Australia
(f) document of identity issued by the Department of Foreign Affairs and Trade to Australian citizens or persons who possess the nationality of a Commonwealth country, for travel purposes
(g) certificate of evidence of resident status.
Primary documents (a) current Australian driver licence, learner permit or provisional
licence issued by a state or territory, showing signature and/or photo and the same name as claimed
(b) Australian marriage certificate issued by a state or territory (church or celebrant-issued certificates are not accepted)
(c) current passport issued by a country other than Australia with a valid entry stamp or visa
(d) current proof of age or photo identity card issued by an Australian government agency in your name with photo and signature
(e) current shooter or firearm licence showing signature and photo (not minor or junior permit or licence)
(f) for persons aged under 18 with no other Primary Use in Community Documents, a current student identification card with photo or signature.
Secondary documents (a) certificate of identity issued by the Department of Foreign
Affairs and Trade (b) document of identity issued by the Department of Foreign
Affairs and Trade (c) convention travel document secondary (United Nations) issued
by the Department of Foreign Affairs and Trade (d) foreign government issued documents (for example driver
licence) (e) Medicare card (f) enrolment with the Australian Electoral Commission (g) security guard or crowd control photo licence (h) evidence of right to a government benefit (Centrelink or
Veterans Affairs) (i) consular photo identity card issued by the Department of
Foreign Affairs and Trade (j) photo identity card issued to an officer by a police force (k) photo identity card issued by the Australian Defence Force (l) photo identity card issued by the Australian Government or a
state or territory government (m) Aviation Security Identification Card (n) Maritime Security Identification card (o) credit reference check; (p) Australian tertiary student photo identity document (q) Australian secondary student photo identity document (r) certified academic transcript from an Australian university (s) trusted referees report (t) bank card (u) credit card.
Change of name If you provide identity documents using a former name, you must provide evidence of your name change. This means providing a change of name certificate issued by the Australian Registry of Births, Deaths and Marriages or an Australian marriage certificate issued by a state or territory, in addition to your four identity documents. Church or celebrant-issued certificates are not accepted.
Special provisions for proof of identity The ACIC recognises that in exceptional circumstances you may not be able to meet the minimum proof of identity requirements. Please contact the accredited body who will assess your ability to meet the requirements and determine the most suitable method to confirm your identity.
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NATIONALLY COORDINATED CRIMINAL HISTORY CHECK | APPLICATION AND INFORMED CONSENT FORM How to submit this form
Before submitting this form, ensure all sections are complete and that you have signed and dated the form.
Submit your completed form and identity documents using these submission instructions:
Mail to: CRIMINAL RECORD SCREENING OFFICE LOCKED BAG 60 PERTH BUSINESS CENTRE WA 6849
Contact details You can contact the accredited body or its legal entity customer for more information on the nationally coordinated criminal history check process, how your personal information is handled and how you can dispute your result.
Accredited body
Department of Health WA Health Support Services
Contact details
Phil Rigg
Senior Screening Officer
- 1300367894
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