Fillable Printable National Criminal Record Check Consent Form - NSW Health
Fillable Printable National Criminal Record Check Consent Form - NSW Health
National Criminal Record Check Consent Form - NSW Health
NATIONAL CRIMINAL RECORD CHECK CONSENT FORM
Provide your full name as well as any other names / aliases by which you have been known.
Employers are required to sight
applicant’s original identifying documents as per 100 point ID check and retain copies of identification documents.
Family Name First Given Name Given Name 2 Given Name 3
Primary Name
Maiden Name
(if applicable)
Complete Previous / Alias Name if any and circle the appropriate name type
Previous/Alias Name 1
Previous/Alias Name 2
Previous/Alias Name 3
Previous/Alias Name 4
Gender
Male
Female
Date of Birth
/ / (dd/mm/yyyy)
Place of Birth
Suburb/Town
:
State: Country:
Current Residential
Address
No/Street:
Suburb/Town:
State: Postcode: Country:
Postal Address
(if same as Residential Address, write
“As Above”)
Previous Address
(if any)
No/Street:
Suburb/Town:
State: Postcode: Country:
Email
Telephone No
Mobile: Business: Private:
Position Applied
Type of Position
Paid Volunteer Other
If you have used one of these documents to verify your identity, please fill in these details:
Driver’s Licence
Number: Issuing State:
Firearms Licence
Number: Issuing Agency:
Passport details
Number: Type
:
Private
Government
UN Refugee
Issuing Country:
1. I acknowledge that I have read the Information sheet provided with this Form and understand that the position for which I am being
considered is in a category for which NO exclusion has been granted from the application of the Spent Convictions Scheme, as
described under the heading “Spent Convictions Schemes” in the Information sheet.
2. I certify that I am the applicant herein and that all the details that I have provided are true and correct and that I have not omitted
any Maiden Name, previous names or aliases that I have used in the past;
3. I acknowledge that any information provided by me on this Form or by Australian Police Services as a result of the records check
may be taken into account by NSW Health in assessing my suitability for the above position.
4. I consent to: (i) my employer forwarding details obtained from this form to NSW Health;
(ii) NSW Health forwarding details obtained from this form to the CrimTrac Agency and/or to Australian police services
or other relevant law enforcement agencies.
5. I consent to:
(i) the CrimTrac Agency making enquiries to Australian Police Services;
(ii) Australian Police Services obtaining and disclosing from their records personal information about me, including any outstanding
charges, criminal convictions and findings of guilt recorded against me for any offences in any jurisdiction, that may be disclosed
according to the laws of the jurisdiction and, in the absence of any laws governing the release of that information, according to
the jurisdiction's information release policy, and forwarding relevant information to the CrimTrac Agency; and
(iii) the CrimTrac Agency providing relevant information to NSW Health for the purposes of allowing NSW Health to assess my
suitability in relation to my employment.
I am aware that if any such records are identified, NSW Health may seek additional information relating to that record from sources such
as courts, police, prosecutors and past employers. I understand that the purpose of seeking this information is to enable a full and
informed employment risk assessment and that where other information is available, NSW Health will obtain that information for
employment risk assessment purposes only. I acknowledge that any information obtained as part of this process may be used by
Australian Police Services for law enforcement purposes including the investigation of any outstanding criminal offences.
Name: Signature: Date: / /
National Criminal Record Check Consent Form (page 2)
GENERAL INFORMATION
This Form is used by NSW Health as part of the assessment process to determine whether a person is suitable for
employment or other engagement for work.
Unless statutory obligations require otherwise, the information provided on this Form will not be used without your prior
consent for any purpose other than in relation to the assessment of your suitability. You may be required to complete
another consent form in the future in relation to employment in other positions.
CRIMINAL HISTORY RECORD CHECK
Criminal history record checks are an integral part of the assessment of your suitability. Information extracted from the
Form will be forwarded to the CrimTrac Agency, other Australian police services or other law enforcement agencies for
checking action. By signing the Form you are providing your consent to these agencies:
a) disclosing criminal history information that pertains to you from their own records to NSW Health; and/or
b) accessing their records to obtain criminal history information that in turn will be disclosed to NSW Health.
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 SCHEMES
New South Wales
In New South Wales the Criminal Records Act 1991 (NSW) governs the effect of a person’s conviction for a relatively
minor offence if the person completes a period of crime-free behaviour, and makes provision with respect to quashed
convictions and pardons.
A “quashed” conviction is a conviction that has been set aside by the Court. A “pardon” means a free and absolute
pardon that has been granted to a person because he/she was wrongly convicted of a Commonwealth, Territory,
State or foreign offence.
In relation to NSW convictions, a conviction generally becomes a “spent conviction” if a person has had a ten year
crime-free period from the date of the conviction. However, certain convictions may not become spent convictions.
These include:
where a prison sentence of more than 6 months has been imposed;
convictions imposed against bodies corporate;
convictions for sexual offences; and
convictions prescribed by the regulations.
For more information on spent convictions in NSW contact NSW Privacy on phone (02) 9268 5588.
Other Australian Police Services
Where a criminal history record with another Australian police service has been obtained, any relevant legislation
(and/or 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 over a certain age. Such convictions (widely
referred to as “spent” or “rehabilitated” convictions) will not be released unless the records check is for the applicant’s
personal information only and provided that this is 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 INFORMATION
You 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 or, if already employed, may lead to your dismissal.
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 in the
form.
