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DEPARTMENT FOR CHILD PROTECTION AND FAMILY SUPPORTRECORD CHECK CONSENT FORMForm 39512/13Applicants to read “Information for Applicant” and complete Parts 1 – 7Please use BLOCK LETTERS and use crosses in boxes marked Part 1: Applicant Details Family Name/Surname (current):Given Names (current):Male: Female: X: Date of Birth:XXXDDMMYYYYCountry of Birth: State/Territory and Town/Suburb of Birth:If you were not born in Australia please state the month and year you arrived in AustraliaMMYYYYDriver’s Licence Number Expiry Date State/Territory of issue Daytime contact phone numberEmail addressAny other name or maiden name/s you have used, including changes by Deed Poll (regardless of the length of time elapsed since you have used the name) Family Name/Surname:Given Names: Period of time known by this nameFrom:YYYYTo:YYYYReason for name change i.e. Marriage, change by Deed Poll etc.Family Name/Surname:Given Names: Period of time known by this nameFrom:YYYYTo:YYYYReason for name change i.e. Marriage, change by Deed Poll etc.Family Name/Surname:Given Names: Period of time known by this nameFrom:YYYYTo:YYYYReason for name change i.e. Marriage, change by Deed Poll etc.Part 2: Current Address of ApplicantUnit Number/Street Number/Street Name (with gap between words)Suburb/Town/Locality State Postcode Period of Residence From:DDMMYYYYPart 3: Previous Residential Address/es (including overseas addresses) Same as your current address You must include previous residential addresses over the last FIVE years (including any overseas addresses). If you do not know the full details of previous addresses please write the name of the suburbs or town/s and state/s. If you do not know the exact dates you lived in the places listed, please write the year you resided there. Previous Residential Address – please start with the most recentUnit Number/Street Number/Street Name (with gap between words)Suburb/Town/Locality State/Territory Postcode Country (if outside Australia) Period of Residence From:DDMMYYYYTo:DDMMYYYYPrevious Residential Address Unit Number/Street Number/Street Name (with gap between words)Suburb/Town/Locality State/Territory Postcode Country (if outside Australia) Period of Residence From:DDMMYYYYTo:DDMMYYYYPrevious Residential Address Unit Number/Street Number/Street Name (with gap between words)Suburb/Town/Locality State/Territory Postcode Country (if outside Australia) Period of Residence From:DDMMYYYYTo:DDMMYYYYPrevious Residential Address Unit Number/Street Number/Street Name (with gap between words)Suburb/Town/Locality State/Territory Postcode Country (if outside Australia) Period of Residence From:DDMMYYYYTo:DDMMYYYYNOTE: If you have had more than four previous addresses in the past five years please record the additional addresses and periods of residence on a separate sheet and attach it to the form. Part 4: Working with Children Card Details If you are the holder of a current Working with Children (WWC) Card, please specify the details here & either attach a copy of your card or have the CPFS or agency officer sight your card and sign below.WWC notice number Expiry dateDDMMYYYYI,(name of WWC Card holder)……………………………………………………., consent to the Working with Children Screening Unit disclosing the result of criminal record checking in relation to me carried out under the Working with Children (Criminal Record Checking) Act 2004 to the Department of Child Protection and Family Support as follows:“no record to release” where the checking indicates that the WWC Screening Unit has received no information indicating that I have been convicted or charged with any offence; or“invalid notice number” where an inquiry does not recognise the Notice Number on my Working with Children Card; or “information not available” where a. or b. do not apply. Applicant’s Signature: Date:DDMMYYYYWWC card & applicant’s signature sighted by: Signature:CARERS, GROUP HOME CARERS AND ADOPTION APPLICANTS TO COMPLETE PART 5 BY LISTING DETAILS OF YOUR PARTNER, OTHER ADULTS AND CHILDREN OVER 10 YEARS LIVING IN YOUR HOME/GROUP HOME. APPLICANTS FOR OTHER ROLES GO STRAIGHT TO PART 6.Part 5: Household Member DetailsPlease record all household members’ details below. Household members 18 years of age and over must also complete their own Record Check Consent Form.Household member 1Family Name/Surname:Given Names (All):Male: Female: X: Date of Birth:XXXDDMMYYYYRelationship to Applicant (e.g. de facto, wife, husband, mother, father, brother, sister, child etc.)Household member 2Family Name/Surname:Given Names (All):Male: Female: X: Date of Birth:XXXDDMMYYYYRelationship to Applicant Household member 3Family Name/Surname:Given Names (All):Male: Female: X: Date of Birth:XXXDDMMYYYYRelationship to Applicant Household member 4Family Name/Surname:Given Names (All):Male: Female: X: Date of Birth:XXXDDMMYYYYRelationship to Applicant Household member 5Family Name/Surname:Given Names (All):Male: Female: X: Date of Birth:XXXDDMMYYYYRelationship to Applicant Household member 6Family Name/Surname:Given Names (All):Male: Female: X: Date of Birth:XXXDDMMYYYYRelationship to Applicant Household member 7Family Name/Surname:Given Names (All):Male: Female: X: Date of Birth:XXXDDMMYYYYRelationship to Applicant Household member 8Family Name/Surname:Given Names (All):Male: Female: X: Date of Birth:XXXDDMMYYYYRelationship to Applicant Part 6: National Criminal History Check – Consent to Obtain Personal Information (Complete Exclusion) (BLOCK LETTERS and in BLACK INK)I, ___________________________________________________________________________ hereby: Family Name (Current)All Given Names (Current)acknowledge that I have read the Spent Convictions Schemes section of the Information sheet and understand that Spent Convictions legislation (however described) in the Commonwealth and many States and Territories protects “spent convictions” from disclosure;understand that the position/entitlement for which I am being considered is in a category for which the following COMPLETE exclusion has been granted from the application of the Spent Convictions legislation and that ALL “spent” convictions and findings of guilt recorded or pending relating to me will be released pursuant to Schedule 3 of the Spent Convictions Act 1988 (WA):employee, student or trainee, volunteer and advisory committee member if the person may, in the course of performing their duties, service and functions, deal with children and their families or with sensitive and confidential information about children and their families;person engaged to provide overnight care to a child or children whether in the person’s home or otherwise;person applying under section 38(1) of the Adoption Act 1994 (WA) to be assessed for suitability for adoptive parenthood.have fully completed this Form, and the personal information I have provided in it relates to me, contains my full name and all names previously used by me, and is correct;consent to the CPFS disclosing personal information about me from this Form to the CrimTrac Agency and the Australian police services;consent to:(i)the CrimTrac Agency disclosing personal information about me to the Australian police services;(ii)the 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(iii)the CrimTrac Agency providing the information disclosed by the Australian police services to the CPFS in accordance with the laws of the Commonwealth; andacknowledge that any information provided by me on this Form, or by the Australian police services, may be taken into account by the CPFS in assessing my suitability for the <specify position/entitlement> ................................................................. for which I am being considered.Applicant’s Signature: Date:DDMMYYYYWitnessing Officer Name: I hereby certify that I have sighted the above applicant’s original identification documents and witnessed his/her signature consenting to this check. Signature: Date:DDMMYYYYNote:The information you provide on this Form, and which the CrimTrac Agency provides to the Department on receipt of the Form, will be used only for the purpose stated above unless statutory obligations require otherwise.WITNESSING OFFICER PLEASE NOTE: You MUST sight the applicant signing the above consent in order to be able to certify that you have witnessed them consenting to the check, therefore you must sign this section on the same date as the applicant.Part 7: Client and Child Protection Check ConsentApplicants who will have contact with children and/or client records must undergo a Client and Child Protection Check. Please Read Before SigningThe CPFS undertakes an individual assessment of a person’s particular CPFS client and child protection record and the inherent requirements of the particular job and the relationship between these.For potential carers, this information will also be reviewed to inform the assessment process and then determine the applicant’s suitability to provide care for a child in a way that promotes the wellbeing of the child and protects the child from harm. An adverse client & child protection record check is one where it is considered that the proposed engagement or continuing employment/service of the individual would place a Departmental or agency client at risk, consistent with the CPFS's duty of care towards the protection and care of children and other vulnerable clients.Adverse information refers to matters where an individual:has contributed to a child being harmed or neglected, orposes a serious risk of harm to a child, or has evidenced behaviour or acts endangering life or health, e.g. serious drug abuse, assaults of a sexual or violent nature, orhas evidenced less serious behaviour which forms a pattern over time and has implications for the suitability of a person to work with children and families e.g. perpetration of family/domestic violence. Information about behaviour that is regarded as less serious but which forms a pattern over time and has implications for the suitability of a person to work with children and families will be considered e.g. perpetration of family/domestic violence. ConsentI certify that the information I have provided on this form is complete and correct.I consent to the CPFS undertaking a search of its client and child protection records as requested by the agency named on this form.I understand that all identifying and Departmental check information about me will be held in the strictest confidence and will not be used for any other purpose than to assist the assessment of my suitability to be engaged by the agency named on this form.I understand that this ‘Consent Form’ will be administered and confidentially retained by the CPFS’s Screening Unit.Applicant’s Signature: Date:DDMMYYYYWitnessing Officer Name: I hereby certify that I have sighted the above applicant’s original identification documents and witnessed his/her signature consenting to this check. Signature: Date:DDMMYYYYWITNESSING OFFICER PLEASE NOTE: You MUST sight the applicant signing the above consent in order to be able to certify that you have witnessed them consenting to the check, therefore you must sign this section on the same date as the applicant.CPFS OR AGENCY OFFICER TO COMPLETE PARTS 8 - 11 & TO WITNESS APPLICANT’S SIGNATURE ON PART 6 &/OR 7 AND SIGHT WWC CARD (if applicable) IN PART 4. Part 8: Authorised Officer Details The Authorised Officer is a CPFS L6+ officer/selection panel chair/SC2+ SCPW PS or nominated agency officer. This is the senior officer who is to be advised of the results of the checks. CPFS Officer Agency Officer Agency Name (if other than CPFS) CPFS DistrictPosition Title (and Level for CPFS officers) Name:Email address: Phone Number:Part 9: Nominated Work Unit Officer/Admin Officer/Business ManagerThe officer nominated here will be contacted regarding queries for this applicant’s checks. Position Title (and Level for CPFS officers) Name:Email address: Phone Number:Part 10: Purpose of CheckIs this an urgent arrangement for the placement of a child under section 79 (2) (b)? Yes ? No ?Please mark the applicable check purpose and ensure that the applicant has completed the relevant parts of the form in full before the form is forwarded to the Screening Unit. General carer assessment Relative/Significant other carer assessment Specific child carer assessment Carer household member (complete part c & d below) Relative Indigenous Community Carer Contractor (Contract For Service) CPFS employee (Permanent appointment – complete parts a, b & c below) CPFS employee (Including fixed term/casual contracts of service - complete part a, b & c below) Adoption applicant Joint Adoption/General carer assessment CPFS volunteers # Student/work experience Non-government agency employee (e.g. group home worker) Non-government agency volunteer Non-government agency carer (e.g. providing care in their own home) Other (please specify e.g. committee member)…………………………………………………………..a) If an employee, contract for/or of service or a volunteer applicant, please specify the position title b) Will the occupant of this position have contact with children in CEO’s care/clients &/or their records? Yes No c) Has the applicant been engaged by CPFS previously? Yes No If yes, how long ago; 0 – 12 months or 12 months or more d) If the applicant is a carer household member you must specify the name of the primary carer.Part 11: 100 Point Proof of Identity CheckCPFS or funded service agency officer must sight original identity documents (see list below) and witness the applicant’s signature in Part 6 &/or 7. Please attach copies of documents sighted wherever possible. (A Justice of the Peace or another public servant may complete this part if it is not practical for a Departmental Officer to do so).The identity documents indicated below have been sighted by;Position Title Name:Email address: Phone Number:Signature: Date:DDMMYYYYA combination of documents (as outlined below) totalling the required 100 points must be sighted, marked on the form and where indicated the details must be recorded on the form. Please check identity documents against the applicant’s details recorded in Part 1 to ensure that they are the same (e.g. spelling, middle names, date of birth etc.)THE ACCEPTABLE 100 POINT COMBINATIONS ARE:COMBINATION 1 A + BCOMBINATION 2B + 3CCOMBINATION 3 A + 2CCOMBINATION 4D (only applicable to applicants who have recently arrived in Australia [within previous 6 weeks] who cannot produce any of the above combinations) SEE FOLLOWING PAGE FOR DOCUMENTS PERMITTED FOR EACH CATEGORY. Please mark identity documents sighted with a and where indicated details must be provided.Category A (1A+1B = 100 points) Current Passport - details must be provided belowPassport number Expiry date:DDMMYYYY An expired Passport – Which has not been cancelled and was current within the preceding 2 years. Details must be provided belowPassport number Expiry date:DDMMYYYY Australian Citizenship certificate Australian Birth Certificate and Marriage Certificate (if your name has changed due to marriage)Category B (1B + 3C’s = 100 points) This includes:An Australian Driver’s Licence;An Australian Firearms Licence; or Any other similar licence; A Tertiary Student Identification Card (must contain a photo and/or signature) ID card issued to a public service employee ID card issued by the Commonwealth, a State or Territory as evidence of a person’s entitlement to a financial benefit e.g. Centrelink Card Remote Community ID Card (only applicable for isolated areas not less than 20 kms from centre point of the nearest urban centre with a census population of not less than 2,500) A written reference from an unrelated person who has known the applicant for a minimum of 12 months (copy of reference must be attached this form)Category C (1B + 3C’s or 1A + 2C’s = 100 points) Medicare card Credit card or account card for a financial institution Bank statement Motor vehicle registration or insurance papers Property rates notice or Property Lease Agreement Home insurance papers Utilities notice (e.g. water, power, gas, telephone) Records from a current or previous employer within the last 2 years (e.g. payslip, group certificate) Proof of Age Card (issued by DPI, WA) A Mortgage Working with Children CardCategory D Passport (please provide details in Category A) Evidence of permanent Australian resident Visa Status/or visa evidence providing permission to work in Australia (copies must be attached)Part 12.1: Referee Reports for Proof of Identity (100 points)This part is only applicable for Aboriginal and Torres Strait Islanders who are living in an isolated area and are unable to provide any of the identification documents listed in Part 11. Refugee applicants may use this Part if necessary. Referee 1Referee Full NameReferee AddressEmail address: Phone Number:I, the above named referee declare that I have known the applicant for …… years and that this is his/her signature hereunder. Applicant Signature: Date:DDMMYYYYReferee Signature: Date:DDMMYYYYReferee 2Referee Full NameReferee AddressEmail address: Phone Number:I, the above named referee declare that I have known the applicant for …… years and that this is his/her signature hereunder. Applicant Signature: Date:DDMMYYYYReferee Signature: Date:DDMMYYYYPlease forward original completed forms and attachments to:ADOPTION APPLICANTSDirectorFostering and Adoption Services Department for Child Protection and Family SupportPO Box 644 COTTESLOE WA 6911ALL OTHER APPLICANTSScreening Unit Department for Child Protection and Family SupportLevel 2, A Block189 Royal StreetEAST PERTH WA 6004Tel: 9222 2978Incomplete consent forms will be returned and this will delay processing. Information for ApplicantGENERAL INFORMATIONThis Form is used by the WA Department for Child Protection and Family Support (“CPFS”) as part of the assessment process to determine whether a person is suitable for employment, other engagement or work (whether as a volunteer or for financial reward) with CPFS. ALL applicants must undergo a national criminal history check. CPFS undertakes an individual assessment of the outcome of a person’s national criminal history check and the inherent requirements of the particular job and the relationship between these. An adverse national criminal history check is one where it is considered that as a consequence of a recorded conviction/finding of guilt, the proposed engagement or continuing employment/service of the individual would place CPFS or agency client at risk, consistent with the CPFS's duty of care towards the protection and care of children and other vulnerable clients. Such offences include:sexual offences; offences of a violent nature (e.g. assault occasioning bodily harm); offences involving the use of firearms or other weapons; drug offences (especially dealing/trafficking); or any other offence(s) that may impact on the CPFS's duty of care towards its clients.Except under extenuating or mitigating circumstances, a person who has been convicted/found guilty of a serious offence as defined in the Spent Convictions Act 1988 (WA) would normally be disqualified from employment/engagement with CPFS.Unless statutory obligations require otherwise, the information provided in this Form and any information received by CPFS in the assessment process will not be used without your prior consent for any purpose other than in relation to the assessment of your suitability. The information will ordinarily be disclosed to the persons and agencies identified in the Form, for that purpose. You may be required to complete another consent form in the future in relation to other positions/other engagement within CPFS.NATIONAL CRIMINAL HISTORY CHECKA national criminal history check is an integral part of the assessment of your suitability. Information extracted from this Form will be forwarded to the CrimTrac Agency and other Australian police services for checking action. By signing the Form you are providing your consent to these agencies:disclosing criminal history information that pertains to you from their own records to CPFS; andaccessing their records to obtain criminal history information that in turn will be disclosed to CPFS.Such criminal history information may include outstanding charges and?criminal convictions/findings of guilt recorded against you that may be disclosed?according to the laws of the relevant jurisdiction and, in the absence of any laws governing the release of that information, according to?the relevant jurisdiction's?information release policy.It is usual practice for an applicant’s personal information to be disclosed to Australian police services for them to use for their respective law enforcement purposes including the investigation of any outstanding criminal offences.SPENT CONVICTIONS SCHEMESWestern AustraliaUnder the provisions of Section 7(1) of the Spent Convictions Act 1988 (WA) only “lesser convictions” can be spent by the WA Police Service, after a time period of 10 years plus any term of imprisonment that may have been imposed. A lesser conviction is one for which imprisonment of 12 months or less, or a fine of less than $15,000 was imposed.All other convictions, such as “serious convictions” applicable under Section 6 of the Act can only be spent by applying to the District Court. At the time of sentencing, the Court may make a “spent conviction order” under the Sentencing Act 1995 (WA) that the conviction is a spent conviction for the purposes of the Spent Convictions Act 1988 (WA).Other Australian police servicesWhere a criminal history record with another Australian police service has been obtained, any relevant legislation (and/or information release policy) affecting that police service will be applied before that record is released. Under various pieces of Commonwealth, State and Territory legislation a person has the right, in particular circumstances or for a particular purpose, to not disclose certain convictions/findings of guilt.? Such convictions (widely referred to as “spent” or “rehabilitated” convictions) will be released in accordance with relevant legislation (and/or release policy).?? Please contact individual police services directly for further information about their release policies and any legislation that affects them.PROVISION OF FALSE OR MISLEADING INFORMATIONYou are asked to certify that the personal information you have provided on this Form is correct. If it is subsequently discovered, for example as a result of a check of police records, that you have provided false or misleading information, you may be assessed as unsuitable.You should note that the existence of a record does not mean that you will be assessed automatically as being unsuitable. Each case will be assessed on its merit, so it is in your interests to provide full and frank details on the Form. ................
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