STAFF-IN-CONFIDENCE (WHEN COMPLETED)

NATIONAL POLICE CHECKING SERVICE

(NPCS)
APPLICATION/CONSENT FORM
(ACCREDITED AGENCIES - CUSTOMERS)

SECTION 1: PERSONAL INFORMATION - Use BLOCK LETTERS and black ink to complete this form. Mark check boxes with an (X)

Given Name Middle Name

Surname

Gender: c Male g
d
e
f
g c Female g
d
e
f c Unknown/Other
d
e
f Date of Birth / /

Place of Birth (Required)

Suburb/Town State Country

Current Residential Address (Required)

Unit No. Street No. Street Postcode

Suburb State Country

Additional Details
If more room is required, list on separate sheet, sign and send the sheet with this application form. Additional sheet included? f
g Yes f
c
d
e g No
c
d
e

Previous names (if applicable)

Given
Middle Name
Name

Surname Type: c Maiden g

d
e
f
g c Previous g
d
e
f c Alias
d
e
f

5 Year Previous Address

Unit No. Street No. Street Postcode

Suburb State Country

5 Year Previous Address

Unit No. Street No. Street Postcode

Suburb State Country

Contact Details

Phone Private Business Mobile

Email

Documents

Aust. Driver's Licence No. State/Territory

Firearms Licence No. State/Territory

Passport No. Passport Country

Passport Type c Private g

d
e
f
g c Government g
d
e
f c UN Refugee
d
e
f

Version 2.1
 STAFF-IN-CONFIDENCE (WHEN COMPLETED)
NATIONAL POLICE CHECKING SERVICE
(NPCS)
APPLICATION/CONSENT FORM
(ACCREDITED AGENCIES - CUSTOMERS)

SECTION 2: PROOF OF IDENTITY (100 - POINT CHECK)

When applying for a national police history check you must provide proof of your identity with your application. You will be asked to provide personal identity documents that add up to at least 100 points. The
combination of documents supplied should, as a minimum, evidence your full name and date of birth. All documents must be originals or certified true copies. Documents must be selected from the list below.
Change of Name
If the name you use to apply for a national police history check is different from that shown on any of your personal identity documents, you must provide evidence of the name change, e.g. Marriage or Change of
Name Certificate issued by a State or Territory Registry of Births, Deaths and Marriages and Divorce papers issued by the Family Court. These documents must be originals or certified true copies and DO NOT
count towards the 100-points. If you use a change of name document you must provide in Section 1 the other names you have used.
You must use ONE Primary document OR At least ONE Secondary Document which MUST contain a photograph

Points
Document Type Document Points Value
Scored

PRIMARY

● Birth Certificate/Birth Extract

● Australian Passport (Current, or expired within the previous two years, but not cancelled)
Only one form of identification accepted from this category 70
● Australian Citizenship Certificate
● International Passport (Current, or expired within the previous two years, but not cancelled)
● Other document of identity having same characteristics as a passport e.g. diplomatic/refugee (Photo or
Signature)

SECONDARY

● Current Licence or Permit (Government Issued)

Your initial Secondary Documents will score 40 points, any
additional documents will be awarded 25 points each
● Working With Children/Teachers Registration Card
● ASIC/MSIC Card
40 or 25
● Public Employee Photo ID Card (Government Issued)
● Department of Veteran Affairs Card
● Centrelink Pensioner Concession Card or Health Care Card
● Current Tertiary Education Institution Photo ID
● Reference from a Doctor (must have known the applicant for a period of at least 12 months)

● Foreign/International Driver’s Licence

● Proof of Age Card (Government Issued)
● Medicare Card/Private Health Care Card
● Council Rates Notice
● Property Lease/Rental Agreement
● Property Insurance Papers
● Tax Declaration 25
● Superannuation Statement
● Seniors Card
● Electoral Roll Registration
● Motor Vehicle Registration or Insurance Documents
● Professional or Trade Association Card

● Utility Bills (e.g. Telephone, Gas, Electricity, Water)

If you wish to use more than one of these documents they must be ● Credit/Debit Card 25
from different organisations ● Bank Statement/Passbook

SPECIAL PROVISIONS ONLY TO BE USED IF 100 POINT CHECK ABOVE CANNOT BE MET

The full 100 point check is required when the applicant has been in
For recent arrivals in Australia (6 weeks or less – proof of arrival date required) current passport 100
Australia for longer than 6 weeks

Aboriginal person or Torres Strait Islander resident in a remote Identity of applicant ordinarily resident in an isolated area verified by TWO persons recognised as ‘Community
70
area/community Leaders’ of the community to which the applicant belongs

● Birth Certificate/Birth Extract

● Australian Passport (current, or expired within the previous two years, but not cancelled)
● Australian Citizenship Certificate
● International Passport (current, or expired within the previous two years, but not cancelled)
Child Under 18 ● Other document of identity having same characteristics as a passport eg. diplomatic/refugee (Photo or 100
Signature)
OR
Statement from an educational institution, signed by the principal or deputy principal, confirming that the child
attends the institution (statement must be on the institution’s letterhead)

TOTAL POINTS

Total Points
Points must equal or exceed a total of 100
Scored:

VERIFICATION - (OFFICE USE ONLY)

I declare that I have sighted and confirmed the applicant’s original or certified true copy personal identity documents and that verification has been achieved using the 100 point check. I am satisfied as to the
correctness of the applicant’s identity.

Signature of person who has confirmed Printed name of person who

_________________________________ _________________________________
100pts of ID: has confirmed 100pts of ID:

Position/Employee Id of person who

_________________________________
has confirmed 100pts of ID: Date:___/___/_______

Version 2.1
 STAFF-IN-CONFIDENCE (WHEN COMPLETED)
NATIONAL POLICE CHECKING SERVICE
(NPCS)
APPLICATION/CONSENT FORM
(ACCREDITED AGENCIES - CUSTOMERS)

SECTION 3: ACCREDITED AGENCY DETAILS

Accredited Agency (Legal Name): MERCURY SEARCH & SELECTION PTY LTD t/a fit2work.com.au ABN: 86 080 799 720

SECTION 4: AUTHORISATION TO DISCLOSE PERSONAL INFORMATION

Is the result of the national police history check to be forwarded/disclosed only to the accredited agency named in Section 3 above? g
c Yes g
d
e
f b No
c
d
e
f
If No: I authorise the result of the national police history check to be forwarded/disclosed to the following employer/organisation:

Employer/Organisation (Legal Name): Ballarat Health Services ABN: 39089584391

SECTION 5: PURPOSE OF THE NATIONAL POLICE HISTORY CHECK

Provide details of relevant position/entitlement, place of work and whether you have contact with vulnerable groups. e.g. Client Services Officer in a call centre, Janitor at a
school, Nurse in aged care facility with direct care of disabled & aged persons or Flight Attendant with direct care of children).

Purpose/Description of Duties ___________________________________________________

SECTION 6: CONSENT TO OBTAIN PERSONAL INFORMATION

National Police History Check

I, __________________________________________________________ __________________________________________________________ hereby:

Given Names (Current) Family Name(Current)

1. acknowledge that I have read the General Information sheet and understand that Spent Convictions legislation (however described) in the Commonwealth and many States and
Territories protects “spent convictions” from disclosure;
2. understand that the national police history check for which I am applying may be in a category for which exclusions from Spent Convictions legislation may apply;
3. 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;
4. acknowledge that the provision of false or misleading information is a serious offence;
5. acknowledge that the Accredited Agency named in Section 3 above is collecting information in this Form to provide to the CrimTrac Agency (an Agency of the Commonwealth of
Australia) and the Australian police agencies;
6. consent to:
i. the CrimTrac Agency disclosing personal information about me to the Australian police agencies;
ii. the Australian police agencies 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;
iii. the CrimTrac Agency providing the information disclosed by the Australian police agencies to the accredited agency named in Section 3 above, in accordance with the
laws of the Commonwealth; and
iv. where applicable, the accredited agency named in Section 3 above disclosing to the employer/organisation named in Section 4 above personal information about me to
assess my suitability in relation to my employment/entitlement; and
7. acknowledge that any information provided by me on this Form, relates specifically to the purpose identified in Section 5 above;
8. acknowledge that any information provided by the Australian police agencies or the CrimTrac Agency, relates specifically to the purpose identified in Section 5 above;
9. acknowledge that personal information that I provide in this Form may be disclosed to the Accredited Agency named in Section 3 above (including contractors or related bodies
corporate) located in Australia or overseas for administrative purposes; and
10. acknowledge that 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.

Note: The information you provide on this Form, and which the CrimTrac Agency provides to the accredited agency named in Section 3 above, on receipt of the Form,
will be used only for the purpose stated above unless statutory obligations require otherwise.

Applicant's Signature: ___________________________________________________ Date: ___/___/_______

Parent/Guardian Consent - If you are under 18 years of age provide consent below from a parent /guardian.

Parent/Guardian Parent/Guardian name

_______________________________ Date: ___/___/______ __________________________________________
Signature printed in full

Office Use

Check Urgency: c Normal g

d
e
f
g c Urgent
d
e
f Type of Check: c Employee g
d
e
f
g c Volunteer
d
e
f Applicant Role: __________________________

Vulnerable People check c Yes g

d
e
f
g c No
d
e
f
(Select YES for Vulnerable People clearance if the applicant’s employment or volunteer role involves care for children, aged persons, persons with a physical or intellectual disability or
mental illness)
Department: _________________________ Supervisor: _________________________ Other Info: __________________________
Version 2.1
 STAFF-IN-CONFIDENCE (WHEN COMPLETED)
NATIONAL POLICE CHECKING SERVICE
(NPCS)
APPLICATION/CONSENT FORM
(ACCREDITED AGENCIES - CUSTOMERS)
GENERAL INFORMATION
GENERAL INFORMATION
This Form is used as part of the assessment process to determine whether a
person is suitable for employment or other engagement for work or other
entitlements.
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.
NATIONAL POLICE HISTORY CHECK
A national police history check is an integral part of the assessment of your
suitability.
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 interest to provide full and frank details in the Form.
Information extracted from this Form will be forwarded to the CrimTrac Agency
and other Australian police agencies1 for checking action. By signing this Form
you are consenting to these agencies accessing their records to obtain and
disclose police history information that relates to you to:
a) the Accredited Agency named in Section 3 above; and
b) where applicable the employer/organisation named in Section 4 above.
Police 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.
SPENT CONVICTIONS SCHEMES
The following information is provided as general guidance and is not exhaustive.
The aim of Spent Convictions legislation2 is to prevent discrimination on the
basis of certain previous convictions. Spent convictions legislation limits the use
and disclosure of older, less serious convictions and findings of guilt.
Spent convictions of specific offences will be released where the check is
required for certain purposes regardless of how old the convictions are. Each
Australian police agency will apply the relevant Spent Convictions
legislation/information release policy prior to disclosure.
If further information or clarification is required please contact the individual
police agencies directly for further information about their release policies and
any legislation that affects them.
Commonwealth
Part VIIC of the Crimes Act 1914 (Cth) deals with aspects of the collection, use
and disclosure of old conviction information. The main element of this law is a
“Spent Convictions Scheme”. The aim of the Scheme is to prevent discrimination
on the basis of certain previous convictions, once a waiting period (usually 10
years) has passed and provided the individual has not re-offended during this
period. The Scheme also covers situations where an individual has had a
conviction “quashed” or has been “pardoned”.
A “spent conviction” is a conviction of a Commonwealth, Territory, State or foreign
offence that satisfies all of the following conditions:
i). it is 10 years since the date of the conviction (or 5 years for juvenile offenders);
AND
ii). the individual was not sentenced to imprisonment or was not sentenced to
imprisonment for more than 30 months; AND
iii). the individual has not re-offended during the 10 years (5 years for juvenile
offenders) waiting period; AND
iv). a statutory or prescribed exclusion does not apply. (A full list of exclusions is
available from the Office of the Australian Information Commissioner).
The law affects Commonwealth authorities in the following ways:
i). a person with a conviction protected by Part VIIC does not have to disclose that
conviction to any person, including a Commonwealth authority, unless an
exclusion applies;
ii). Commonwealth authorities are prohibited from accessing, disclosing or
taking into account spent convictions of Commonwealth offences.
Part VIIC and Crimes Regulations 1990 provide for “statutory” or “regulatory”
exclusions that will prevent certain Commonwealth convictions from being spent
in certain circumstances.
Queensland
Under Queensland’s Criminal Law (Rehabilitation of Offenders) Act 1986 a
conviction automatically becomes spent upon completion of the prescribed
(rehabilitation) period. This period is:
(i) 10 years for indictable offences where the offender was an adult at the time of
conviction; and
(ii) 5 years for other (summary offences or where the offender was a juvenile).
Where a person is convicted of a subsequent offence (an offence other than a
simple or regulatory offence) during the rehabilitation period, the period runs from
the date of the subsequent conviction.
Convictions where the offender is sentenced to more than 30 months
imprisonment (whether or not that sentence is suspended) are excluded from the
regime.
Once the rehabilitation period has expired, it is lawful for a person to deny
(including under oath) that the person has been convicted of the offence, and the
conviction must be disregarded for occupational licensing purposes (subject to
certain exceptions, see below). It is unlawful for any person to disclose the
conviction unless:
(i) the convicted person consents;
(ii) the Minister has granted a permit authorising disclosure (where there is a
legitimate and sufficient purpose for disclosing);
(iii) the disclosure is subject to an exemption.
Victoria Police
For the purposes of employment, voluntary work or occupational
licensing/registration, police may restrict the release of a person’s police record
according to the Victoria Police “Information Release Policy”. If you have a police
record the “Information Release Policy” may take into account the age of the police
record and the purpose for which the information is being released. If 10 years
have elapsed since you were last found guilty of an offence, police will, in most
instances, advise that you have no disclosable court outcomes. However, a record
over 10 years may be released if:
(i) it includes a term of imprisonment longer than 30 months;
(ii) it includes a serious, violent or sexual offence and the check is for the purpose
of working with children, elderly people or disabled people;
(iii) it is in the interests of crime prevention or public safety.
Findings of guilt without conviction and good behaviour bonds may be released.
Recent charges or outstanding matters under investigation that have not yet gone
to court may also be released.
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 10 year crime-free period from the date of the conviction.
However, certain convictions may not become spent. These include:
(i) where a prison sentence of more than 6 months has been imposed (periodic or
home detention is not considered a prison sentence);
(ii) convictions against companies and other corporate bodies; (iii) sexual
offences pursuant to the Criminal Records Act 1991; and
(iv) convictions prescribed by the Regulations
1 Australian Federal Police, The New South Wales Police Force, Victoria Police,
Queensland Police Service, South Australia Police, Western Australia Police,
Tasmania Police Service, Northern Territory Police Force.
2 Applicable spent conviction legislation, as amended from time to time.
Version 2.1
 STAFF-IN-CONFIDENCE (WHEN COMPLETED)
NATIONAL POLICE CHECKING SERVICE
(NPCS)
APPLICATION/CONSENT FORM
BACKGROUND EMPLOYMENT CHECKS
GENERAL INFORMATION (continued)
Tasmania
Under the Annulled Convictions Act 2003 (Tas) a conviction is annulled upon
completion of the prescribed period of good behaviour. This period is:
(i) 10 years where the offender was an adult at the time of conviction; or
(ii) 5 years where the offender was a juvenile at the time of conviction.
A person is taken to be of good behaviour for the required period if, during that
period, he or she is not convicted of an offence punishable by a term of
imprisonment. If the person is so convicted, the qualifying period (for the original
offence) starts to run from the date of the subsequent conviction. A subsequent
traffic conviction is only taken into account for prior traffic offences (except more
serious traffic offences which cause injury or death).
Only “minor” convictions can become annulled. A minor conviction is a conviction
other than one for which a sentence of imprisonment of more than 6 months is
imposed, a conviction for a sexual offence or a prescribed conviction. A minor
conviction is also annulled if the offence ceases to be an offence.
Once an offence is annulled the convicted person is not required to disclose any
information concerning the spent conviction. Any question concerning criminal
history is taken only to apply to unspent convictions, and references in Acts or
statutory instruments to convictions or character or fitness do not include spent
convictions. An annulled conviction or the non-disclosure of the annulled
conviction is not grounds for refusing the person any appointment, post, status
or privilege or revoking any appointment, post, status or privilege.
(i) a person is not required to disclose the existence of the conviction;
(ii) questions relating to convictions and a person’s criminal record will be taken
only to apply to unspent convictions;
(iii) it is unlawful for another person to disclose the existence of a spent
conviction except as authorised by the Act;
(iv) spent convictions are not to be taken account in making decisions about the
convicted person’s character or fitness.
South Australia
Release of information on a National Police Check is governed by the South
Australian Spent Convictions Act 2009. It is an offence to release information
regarding the convictions of a person if those convictions are deemed to be
‘spent’ under the Act.
A spent conviction is one that cannot be disclosed or taken into consideration for
any purpose. Eligible convictions become spent following a 10-year conviction
and proven offence-free period for adults, and a 5-year conviction and proven
offence-free period for juveniles.
The Act defines a conviction as:
i). a formal finding of guilt by a Court;
ii). a finding by a Court that an offence has been proved.
Certain convictions can never be spent. These include but are not limited to:
i). convictions of sex offences;
ii). convictions where a sentence is imposed of more than 12 months
imprisonment for an adult, or 24 months imprisonment for a juvenile.
Schedule 1 of the Act sets out a number of exceptions to the rule where spent
convictions can be released. Some examples of this include:
i). the care of children;
ii). the care of vulnerable people (including the aged and persons with a
disability, illness or impairment);
iii). activities associated with statutory character tests for licensing
Interstate offences are released in accordance with that State or Territory's spent
conviction / rehabilitation legislation and policy. Intelligence-type information is
not released.
Western Australia
Under the provisions of Section 7(1) of the Spent Convictions Act 1988 (WA) only
“lesser convictions” can be spent by Western Australia Police, 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).
Australian Capital Territory
Generally, under the Spent Convictions Act 2000 (ACT), a conviction becomes
spent automatically at the completion of the prescribed (crime-free) period. This
period is:
(i) 10 years for convictions recorded as an adult; or
(ii) 5 years for convictions recorded as a juvenile.
The period begins to run from the date a sentence of imprisonment is completed,
or, where no sentence of imprisonment is imposed, from the date of conviction. A
person must not be subject to a control order or convicted of an offence
punishable by imprisonment during this period. If a person is convicted of an
offence, which was committed in the crime-free period, but the conviction is not
incurred until after the crime-free period, the spent conviction may be revived and
will not become spent again until the offender has achieved the relevant crime-free
period in respect of the later offence.
The effect of conviction becoming spent is that:
(i) the convicted person is not required to disclose any information concerning the
spent conviction;
(ii) any question concerning criminal history is taken only to apply to unspent
convictions;
(iii) references in Acts or statutory instruments to convictions or character or fitness
does not include spent convictions, and it is an offence to disclose information
regarding spent convictions;
(iv) it is unlawful for a person who has access to a person’s criminal record held
by a public authority to disclose a spent conviction;
(v) it is unlawful for a person to fraudulently or dishonestly obtains information
about a spent conviction from records kept by a public authority.
Northern Territory
Under the Criminal Records (Spent Convictions) Act 1992 (NT), a conviction
becomes spent automatically (in the case of an adult or juvenile offender convicted
in a Juvenile Court) and by application to the Police Commissioner (in the case of
a juvenile convicted in an adult court) upon completion of the prescribed period.
The prescribed period is:
(i) 10 years for offences committed while an adult; and
(ii) 5 years for offences committed as a juvenile
The period starts on completion of any sentence of imprisonment. A subsequent
traffic conviction is only taken into account for prior traffic offences (except more
serious traffic offences which cause injury or death). Once a conviction becomes
spent:
(i) a person is not required to disclose the existence of the conviction;
(ii) questions relating to convictions and a person’s criminal record will be taken
only to apply to unspent convictions;
(iii) it is unlawful for another person to disclose the existence of a spent conviction
except as authorised by the Act;
(iv) spent convictions are not to be taken account in making decisions about the
convicted person’s character or fitness.
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.
It is a serious offence to provide false or misleading information
Version 2.1
 Persons Authorised to Certify Documentation

Persons Authorised to Certify Documentation

In a situation where you are unable to bring your original 100 points of ID to be physically sighted by the organisation, you may have copies officially certified by a

person listed below. Documents only need to be certified if you are unable to provide the original documents to the organisation performing the check.

1. Only persons holding positions identified below are authorised to certify documentation for the undertaking of a National Police History Check (NPHC). The

exception to the list is where a potential conflict of interest may arise, such as certifying a family members identification

2. Authorised persons, in certifying a NPHC document, MUST:

1. Sight ORIGINAL documentation

2. Verify that the photocopy is a true and accurate record of the original document

3. Verify that the photographic identification is a true and accurate likeness of the applicant

4. Declare on the document to be signed that it is a ‘true and accurate record of the original document

5. Sign and date each photocopy as a true and accurate record of the original document

6. Print your name and position (authorised position – below) on each document to be certified

3. Applicants must ensure that documents must be certified in accordance with the above

- Australian Lawyer (Legal Profession Act 2004) - Justice of the Peace, Bail Justice or Register of the magistrate’s Court

- Registered Medical Practitioner - Permanent employee of Australia Post with 5 or more years continuous service

- Pharmacist - Permanent employee with 5 or more years of continuous service of:

- Member of the police force (a) the Commonwealth or a Commonwealth authority; or

- Principal/teacher in the teaching service (b) a State or Territory or a State or Territory authority; or

- Registered Nurse (c) a local government authority;

- Secretary of building society - Senior Executive Service employee of:

- Councillor of a Municipality (a) the Commonwealth or a Commonwealth authority; or

- Public Notary (b) a State or Territory or a State or Territory authority

- Veterinary Practitioner - Accountant (member of the ICA,ASA or NIA)

- Registered Dentist (Dental Practice Act 1999) - Bank manager of employee with 5 or more years of continuous service

- Minister of Commonwealth or State Parliament

- Casino special employee

Version 2.1
 Name: ______________________________________

Position: ____________________________________

Date of Birth: ________________________________

Health and Capacity Declaration

Ballarat Health Services is committed to promoting and protecting the health, safety and well-being of all
employees. To achieve this, the Health Service strives to ensure that employees are not required or permitted to
undertake work for which they are not suited and to take appropriate measures to allow work to be done in a
manner which will not put any person at risk. Where you have a pre-existing injury and/or disease, consideration
will be given to reasonable modifications to the environment or tasks.

To assist the Health Service to achieve this objective, please complete the information. The information you
provide is confidential and will be treated in accordance with relevant legislation including the Information Privacy
Act 2000 (Vic), and the Health Records Act 2001 (Vic). If you are the preferred candidate following our selection
process and have declared an illness/injury, this declaration will be viewed in conjunction with the relevant position
description; the purpose being to determine any reasonable and appropriate actions that may be taken to ensure
the health and wellbeing of staff is not put at risk.

If you are unsuccessful in gaining a position at Ballarat Health Services, your completed Health and Capacity
Declaration will be destroyed in accordance with the requirements of the Public Records Act 1973 (Vic).

Important Note Regarding Failure to Disclose Information

If you fail to disclose information or if you provide false or misleading information you and your dependents may not
be entitled to WorkCover benefits in the event of any recurrence, aggravation, acceleration, exacerbation or
deterioration of a pre-existing injury or disease, arising out of, or in the course, or due to the nature of this
employment with Ballarat Health Services.

If you are successful in your application, but are found to have failed to disclose information or provided false or
misleading information, Ballarat Health Services will institute disciplinary action, and will consider terminating your
employment.

As far as you are aware, do you now have, or have you ever had, any of the following: (please tick as many
that apply)

Yes No Yes No
  A condition that lowers your immunity   Any other significant medical condition
  Dermatitis / Eczema   Significant Back injury/sciatica
  Heart disease / chest pain   Asthma
  Significant arm, shoulder, elbow or hand injury   Significant neck injury
  Repetitive strain injury   Epilepsy
  Significant foot pain/injury   Diabetes
  Significant leg, hip, knee or ankle injury   Hearing problems
  Arthritis/rheumatism/painful joints/gout   Vision defect
  Psychiatric illness   Chickenpox
  Fear of confined spaces   Tuberculosis
  Fear of heights   Hepatitis B/Hepatitis C
If you have checked ‘YES’ to any of the boxes above, please give details on the following page.

1
Please provide details of boxes checked ‘YES’ from previous page

Illness, injury When Has it Type of treatment How Have you

condition did it ceased? eg. Surgery/other (please detail) long off completely
start? work? recovered?

Have you any known allergies or had a skin reaction to latex or other substances?

Yes  No  If ‘YES’, provide detail _________________________________________

___________________________________________________________________________________________

Do you have a condition that requires you to carry medication with you at all times?

Yes  No  If ‘YES’, provide detail _________________________________________

___________________________________________________________________________________________

Have you ever:

 Left a job or changed occupation because of your health? Yes  No 

 Suffered an injury that has left you with a permanent disability? Yes  No 
 Applied for Workers Compensation? Yes  No 
If ‘YES’, please answer these questions relating to the Worker’s Compensation claims you may have made.

Your employer? Date of What happened/what was the Time Lost Result
Injury injury/illness? 1. Full recovery
2. Work
restrictions
3. Permanent
disability

2
Employee Declaration

The following declaration is made for the purposes of Sections 82(7)-(9) of the Accident Compensation Act 1985.

I, ………………………………………………………………………. (insert name of applicant) declare that:

1. I have read and understood this form, including the information above.
2. I acknowledge that I am required to disclose all pre-existing injuries or diseases which I believe may be
affected by my undertaking the job of …………………………………... (insert position title)

Please select appropriate response

Are you aware of any illness, condition, injury or disease that you have or have had that is likely to recur or
deteriorate, accelerate or be exacerbated or aggravated by the key activities required to be undertaken by the
role, as listed in the Position Description?

Yes  No 
If Yes, please list illness, condition, injuries/diseases & how this/these are currently being managed.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

I acknowledge that any non-disclosure or false or misleading information on my part may result in section 82(8) of
the Accident Compensation Act being applied. This would disentitle me or my dependents from receiving benefits
relating to any recurrence, aggravation, acceleration, exacerbation or deterioration of any pre-existing injury or
disease which I may have.

To the best of my knowledge the information provided in this Declaration is true and correct.

DATED: day of 20

________________________________ ____________________________________
Signature of applicant Signature of witness

________________________________ ____________________________________
Printed name of applicant Printed name of witness

3
AUTHORISATION TO APPOINT

I authorise this applicant as a suitable candidate to undertake the duties of this role:

YES  NO 

Actions Required

If YES, please indicate whether there are any special circumstances, immunizations, modification requirements to
work area or resources, or any other considerations that will need to be taken into account to ensure the safety of
this applicant in this role (please specify):

______________________________________ Print Name: ______________________________________

SIGNATURE

If there are any concerns arising from this declaration that may pose a risk to the health and wellbeing of a
preferred applicant, this form will be referred to the Injury Management Advisor. The Injury Management Advisor
will arrange a meeting between the relevant manager and the applicant to determine any reasonable and
appropriate action that may need to be taken to ensure that the applicant’s health and wellbeing is not being put at
risk.

4
 5

Staff Pre Employment Immunisation Questionnaire

Ballarat Health Services employment guidelines require all Category A & B Health Care Workers to provide
evidence of either pathology results or documented immunisations for certain diseases prior to commencing
employment. Documented immunisations/pathology results may be obtained from your GP, previous employer,
your local council where you attended school or Medicare. If you are unable to provide evidence of immunity or an
immunisation record you will be contacted and requested to undergo routine pathology screening to assess your
immunity. A copy of Ballarat Health Service’s immunisation policy is available on the Ballarat Health Services
Website. (see the back of this form for risk category A & B Health Care Workers)

Please complete and return this mandatory form with your pathology/immunisation results to Human
Resources at the time of your interview. Failure to complete this form may delay the progress of your
application for employment at Ballarat Health Services.
Name: Employee No:
D.O.B. Mobile No:
Position: Department:
Address: Email:
I declare that the information I have provided is correct:
Signature: Date:

□ I have attached copies of all required immunisation and pathology immunisation results (see risk categories on
the back of this form)
1. PATHOLOGY RESULTS required as evidence indicating immunity to the Office Use Only
following vaccine preventable diseases: (please circle the relevant responses)
Hepatitis B Pathology results Yes/No Attached
provided
Chickenpox Pathology results Yes/No Attached
provided
Measles Pathology results Yes/No Attached
provided
Mumps Pathology results Yes/No Attached
provided
Rubella Pathology results Yes/No Attached
provided
2.VACCINATION RECORD (copy acceptable) is compulsory as evidence of
immunity to the following vaccine preventable diseases (please circle the relevant
responses)
Diptheria, Tetanus, Pertussis: Have you received a Diphtheria, Tetanus, Pertussis Attached
containing vaccine (dTpa) as an adult? Yes/No

Measles, Mumps, Rubella (MMR) immunisation (only if born after 1966) Attached
Have you received 2 doses of MMR? Yes/No
Varicella (chickenpox) immunisation Attached
Have you received varicella immunisation? Yes/No
3. Tuberculosis: (please circle the relevant responses)
Have you had a Quantiferon Gold blood test? Yes/No RESULTS PROVIDED Attached
Have you had a Mantoux test? Yes/No RESULTS PROVIDED Attached
Assessment of risk of TB infection
Were you born outside Australia? Yes/No
If yes, where were you born?
Have you lived or travelled overseas? Yes/No
Country & amount of time lived/travelled in country
Have you ever had contact with a person known to have TB? Yes/No

2014
 6

Ballarat Health Service immunisation program has been developed to ensure the safety and protection of both
patients and healthcare workers. The potential for health care workers to be exposed to and transmit vaccine
preventable diseases such as hepatitis B, influenza, measles, rubella and pertussis if not immune is high.
Maintaining immunity in the healthcare worker population helps to prevent transmission of vaccine preventable
diseases to and from health care workers and patients, and is therefore a key health and safety prevention initiative
to transmission of infection and disease at Ballarat Health Services.

RISK CATEGORIZATION:
Health Care workers may be categorised into groups according to the likelihood of their exposure to potentially
infectious agents as follows:

Category Risk Example

A Direct contact with blood or body Dentists, medical practitioners, nurses,
substances. This category includes all allied health practitioners, health care
persons who have physical contact with, or students, laboratory staff, mortuary staff,
potential exposure to, blood or body engineering staff, CSSD staff, environmental
substances service staff, security staff, ward assistants,
personal care assistants and staff
responsible for the decontamination and
disposal of contaminated materials,
psychologists.
B Indirect contact with blood and body Catering staff, ward clerks, pharmacy staff,
substances. Rarely have direct contact program assistants.
with blood or body substances. These
employees may be exposed to infections
spread by the airborne or droplet routes,
but are unlikely to be at occupational risk
from blood borne diseases.
C Minimal patient contact. Office clerical staff, gardening staff,
Occupational groups that have no greater volunteers, work experience students.
exposure to infectious diseases than do
the general public. The exact nature of job
responsibilities should be taken into
account when deciding immunisation
requirements and all staff should be
encouraged to be fully vaccinated.

*Office Use Only

Date received in HR:
Date received in Infection Control:
Date processed:
Approval to appoint: YES NO Signature:

Category: A B C (no further action required)

Recommendations:
Quantiferon Gold Mumps Ab level Dtpa (Boostrix) MMR immunisation
Assay
Hepatitis B Ab Rubella Ab level Influenza Varicella
level vaccination immunisation
Measles Ab level Varicella Ab level Hepatitis B
immunisation

Infection Prevention & Control Unit, 53204788

2014
 Commonwealth of Australia
STATUTORY DECLARATION
Statutory Declarations Act 1959

I,
(Name of person making the declaration)

(Address)

(Occupation)

make the following declaration under the Statutory Declarations Act 1959:

I declare that (place a tick or cross in applicable boxes):

⃞ since turning 16 years of age, I have resided in an overseas country for more than 12 months continuously in the
last 10 years.
⃞ since turning 16 years of age, I have been a citizen or permanent resident of a country/countries other than
Australia.
⃞ since turning 16 years of age, I have never been a citizen or permanent resident of a country/countries other than
Australia.

I declare that I have never been:

(a) convicted of murder or sexual assault; or

(b) convicted of, and sentenced to imprisonment for, any other form of assault;

(c) convicted of any other offence which may preclude me from working in the appointed role.

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence
under Section 11 of the Statutory Declarations Act 1959,

and I
(signature of person making declaration)

on of believe that the statements in this declaration are true

(day) (month and year)
in every particular.

Declared at
(Place)

Before me:
(Signature of person before whom the declaration is made (see over)

________________________________________________________________
(Full Name of person before whom the declaration is made (in printed letters)

(Qualification)

________________________________________________________________
(Address of person before whom the declaration is made)

Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which
is imprisonment for a term of 4 years - see section 11 of the Statutory Declarations Act 1959.

Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 - see section 5A of the
Statutory Declarations Act 1959.
A statutory declaration under the Statutory Declarations Act 1959 may be made before-
(1) a person who is currently licensed or registered under a law to practise in one of the following occupations:
Chiropractor Dentist Legal practitioner Medical practitioner
Registered Nurse Optometrist Patent attorney Pharmacist
Physiotherapist Psychologist Trade marks attorney Veterinary surgeon
(2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of
Australia, as a legal practitioner (however described); or
(3) a person who is in the following list:
Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public
Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)
Bailiff
Bank officer with 5 or more continuous years of service
Building society officer with 5 or more years of continuous service
Chief executive officer of a Commonwealth court
Clerk of a court
Commissioner for Affidavits
Commissioner for Declarations
Credit union officer with 5 or more years of continuous service
Employee of the Australian Trade Commission who is:
(a) in a country or place outside Australia; and
(b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and
(c) exercising his or her function in that place
Employee of the Commonwealth who is:
(a) in a country or place outside Australia; and
(b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and
(c) exercising his or her function in that place
Fellow of the National Tax Accountants' Association
Finance company officer with 5 or more years of continuous service
Holder of a statutory office not specified in another item in this list
Judge of a court
Justice of the Peace
Magistrate
Marriage celebrant registered under Subdivision C of Division I of Part IV of the Marriage Act 1961
Master of a court
Member of Chartered Secretaries Australia
Member of Engineers Australia, other than at the grade of student
Member of the Association of Taxation and Management Accountants
Member of the Australasian Institute of Mining and Metallurgy
Member of the Australian Defence Force who is:
(a) an officer; or
(b) a non-commissioned officer within the meaning of the Defence Force Discipline Act
1982 with 5 or more years of continuous service; or
(c) a warrant officer within the meaning of that Act
Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified
Practising Accountants or the National Institute of Accountants
Member of:
(a) the Parliament of the Commonwealth; or
(b) the Parliament of a State; or
(c) a Territory legislature; or
(d) a local government authority of a State or Territory
Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961
Notary public
Permanent employee of the Australian Postal Corporation with 5 or more years of continuous
service who is employed in an office supplying postal services to the public
Permanent employee of:
(a) the Commonwealth or a Commonwealth authority; or
(b) a State or Territory or a State or Territory authority; or
(c) a local government authority;
with 5 or more years of continuous service who is not specified in another item in this list
Person before whom a statutory declaration may be made under the law of the State or Territory in
which the declaration is made
Police officer
Registrar, or Deputy Registrar, of a court
Senior Executive Service employee of:
(a) the Commonwealth or a Commonwealth authority; or
(b) a State or Territory or a State or Territory authority
Sheriff
Sheriffs officer
Teacher employed on a full-time basis at a school or tertiary education institution