DCS Inclusion - Screening Unit - Home

Department for Communities and Social Inclusion - Screening Unit - Home

Employment and Volunteer Screening Application

Application Number: AP1541070

A - Your personal details

B - Your previous and preferred names

C - Your current contact details

D - Your previous residential addresses

E - Employment / Placement / Volunteer Details

F - Declaration

Please answer 'Yes' or 'No' for all of the questions in this section.

If you answer 'Yes', you will need to tell us some more information in the text box that appears. Please include information like:

• dates
• decisions and the reasons for the decisions
• conditions of employment
• offence type
• court details
• status of any proceedings

 

1*

Have you ever been dismissed or resigned from any employment or a volunteer role in response to or following allegations of improper conduct relating to children?

Yes

No

2*

Have you been (or are you currently) the subject of any professional disciplinary proceedings, or any action that might lead to such proceedings in any jurisdiction? (not including criminal court proceedings).

Yes

No

3*

Have you ever been (or are you currently) subject to any restrictions regarding your contact with children (including removal of a child) in any employment, volunteer, or personal capacity?

Yes

No

4*

Have you ever been found guilty of an offence committed in a country other than Australia, including an offence for which no conviction was recorded?

Yes

No

5*

Have you been named as the defendant in an Interim or Confirmed Intervention Order, Restraining Order, Apprehended Violence Order, Domestic Violence Restraining Order, Paedophile Restraining Order or equivalent, in any jurisdiction?

Yes

No

6*

Are you currently or have you ever been a registrable sex offender? (e.g. Australian National Child Sex Offender Register)

Yes

No

7*

Have you ever been denied an employment screening clearance or working with children clearance from another Australian jurisdiction?

Yes

No

8*

Are you currently suspended, or have you ever been refused, barred, excluded, prohibited, or disqualified following an application for an NDIS Worker Screening Check, Working With Children Check, Working With Vulnerable People Registration and/or working with people with a disability check (or equivalent) in any state or territory in Australia?

Yes

No

9*

Have you ever been subject of an investigation by any government agency anywhere in Australia that involved allegations of abuse or neglect of a child in your care that resulted in restrictions regarding your contact with that child or other children (including the removal of a child/children)?

Yes

No

10*

Have you ever been dismissed or resigned from any employment or a volunteer role in response to or following allegations of improper conduct relating to a child, elderly person or person with disability?

Yes

No

11*

Have you ever submitted an application for employment or a volunteer role involving contact with children, people with a disability, or elderly persons which was declined for disciplinary reasons or allegations of improper conduct?

Yes

No

12*

Have you been named as the defendant in an Interim or Confirmed Intervention Order, a Domestic Violence Order, a Restraining Order, an Apprehended Violence Order, Domestic Violence Restraining Order, a Paedophile Restraint Order, a Child Protection Order, or equivalent, in any jurisdiction?

Yes

No

==

G - Consent to obtain personal information

I, Sejin Pak hereby:

• Acknowledge that I understand the information on this form.

• Declare that the personal information I have provided on this form relates to me.

• Declare I have fully and accurately completed this form, my personal information is complete and correct, and contains my full name and all names I have been known by or used, including previous names, aliases, and informal names.  

• Acknowledge that withholding and/or providing misleading or false information on this form and in any supplied identity documents I may have provided is a Commonwealth offence and may lead to prosecution under the Criminal Code Act 1995 (Cth)

• Acknowledge that if I have provided false, misleading, incorrect, or incomplete information my application will be cancelled without refund and any clearance I hold will be revoked.

• Acknowledge that any information sent by mail or electronically, in relation to this form, including any supplied identity documents, is sent at my risk and I am aware of the consequences of sending information in these ways.

• Consent to the Department of Human Services’ (DHS) Screening Unit (ABN 11 525 031 744) accessing personal information I have provided in previous screening applications, which was collected by the DHS Screening Unit with my consent, for the purpose of the DHS Screening Unit using and disclosing this information to undertake functions I have consented to it performing as part of this application. 

• Understand that the employers and/or organisations that engage me in work related to the purposes of the screening check/s contained in this application shall make the final decision as to my engagement in the position.

• Understand that decisions made regarding complex risk assessments may be determined by a panel of DHS senior officers.

• Acknowledge that the DHS Screening Unit 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 related to the screening check/s I have applied for in this application form.

• Acknowledge that I am aware that I am providing consent for a nationally coordinated criminal history check to be conducted using all personal information provided in this form and provided in any supplied identity documents.

• Give consent to:
  • the ACIC and police agencies using and disclosing my personal information that have provided in this form and personal information contained in any supplied identity documents to conduct a nationally coordinated criminal history check.
  • The ACIC disclosing the police information sourced from the police agencies to the DHS Screening Unit.
  The storage of my personal and police information off-shore (Japan) in Salesforce cloud-based storage software.

• Understand and acknowledge that the ACIC and Australian police agencies will disclose police information about me to the DHS Screening Unit which may include, but is not limited to, convictions, findings of guilt, pending charges, spent convictions, non-conviction outcomes, and circumstantial information relating to offences committed or allegedly committed by me, regardless of when and where the offence or alleged offence occurred, and what the outcome may have been.

• Understand and acknowledge that it is usual practice for my 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).

• Understand and acknowledge that the DHS Screening Unit will use or disclose personal information, police information, or other sensitive information about me in accordance with the Privacy Act 1988 (Cth), Australian Privacy Principles (APPS), Information Privacy Principles (IPPS) Instruction and when:  
  • it is legally required or authorised, such as by an Australian law, or court or tribunal order,   
  • the DHS Screening Unit believes on reasonable grounds that the use and disclosure of the information is necessary to prevent or lessen a serious threat to my life, the health or safety of some other person, or to public health or safety,
  • the DHS Screening Unit believes the use is reasonably necessary for the enforcement of the criminal law or of a law imposing a pecuniary penalty or for the protection of the public revenue or for the protection of the interests of the government, statutory authority or statutory office-holder as an employer,
  • the DHS Screening Unit has reason to suspect that unlawful activity has been, is being or may be engaged in, and discloses the information in reporting our concerns to relevant persons or authorities, or,
  • the Screening Unit reasonably believe that the use relates to information about an individual that suggests that the individual has engaged or may engage in illegal conduct or serious misconduct in relation to a person; and the Screening Unit reasonably believes that the use is appropriate in the circumstances; and the use complies with any guidelines issued by the Minister of the Department of Human Services for the purposes of this clause.

• Consent to the DHS Screening Unit obtaining a recent photograph from me when required and in form determined by the DHS Screening Unit.

• Understand and acknowledge that, for the purpose of a working with children check, the DHS Screening Unit, being the central assessment unit established under the Child Safety (Prohibited Person) Act 2016 (SA), is authorised to receive and make use of information related to me that is relevant to performing its functions under the Child Safety (Prohibited Person) Act 2016 (SA) from any person or body in South Australia or any other jurisdiction including, but not limited to, information from:
  • police services,
  • courts,
  • prosecuting authorities,
  • government agencies,
  • statutory authorities,
  • my employer/s.

• Understand and acknowledge that, for the purpose of a working with children check, the DHS Screening Unit, is authorised to disclose information related to me (not being information classified by the Commissioner of Police as criminal intelligence) in the possession of the DHS Screening Unit to a prescribed person or body in another State or Territory for purposes related to the screening of me to work with children (being a person or body whose official function consists of or includes the screening of persons who work with children (however described); or any other person or body prescribed by the Child Safety (Prohibited Persons) Regulations 2019 (SA) for the purposes of this clause.

• Understand and acknowledge that, for the purpose of a working with children check, the DHS Screening Unit is authorised to disclose information related to me, in the possession of the DHS Screening Unit, when compelled to do so in accordance with a law of the State of South Australia or the Commonwealth.

• Consent to the DHS Screening Unit, providing my relevant criminal history information, to the public sector agency who has requested a working with children check be conducted in relation to me, where the DHS Screening Unit has an existing agreement in place with the agency to do so to enable the agency to use my relevant criminal history information for purposes authorised under the legislative and regulatory instruments governing that agency’s functions.

• Understand and acknowledge that, for the purpose of a working with children check, in accordance with the Child Safety (Prohibited Person) Act 2016 (SA), the DHS Screening Unit will notify all my known employers and/or organisations I volunteer with, who have registered to notified, if I become a prohibited person through the operation of section 15 of the Child Safety (Prohibited Person) Act 2016 (SA).

• Understand and acknowledge the DHS Screening Unit, will conduct an additional working with children check on me, upon receipt of new or additional information to determine if I am prohibited or not prohibited from engaging in child related work.

• Understand and acknowledge that, for the purpose of a working with children, where the DHS Screening Unit, determines I am not prohibited from engaging in child related work that the organisation and, where applicable, the relevant government supervisory agency, contemplating engaging me in child related work, shall make the final determination as to my suitability to be engaged.

• Consent to a nationally coordinated criminal history check being made in relation to me for the purpose of an additional or further working with children check being conducted under section 30 and section 33 of the Child Safety (Prohibited Persons) Act (SA).

• Consent to a nationally coordinated criminal history check being made in relation to me for the purpose of the DHS Screening Unit reconsidering a decision to prohibit me from working with children check pursuant to an order made by the South Australian Civil and Administrative Tribunal.

• Understand and acknowledge the DHS Screening Unit may disclose information about me obtained in the operation or administration of the Child Safety (Prohibited Persons) Act (SA) for the purpose of providing relevant information for entry in a national register or database relating to the screening of persons who work with children.

Do you agree and consent to the above?

Yes

 

No

Your personal information

The DHS Screening Unit collects, uses and stores your personal information solely for the purpose of assessing your screening application — in compliance with the Australian Privacy Principles and the DHS Code of Fair Information Practice.

Personal information will not be disclosed to any third party without your consent, unless disclosure is required by law or protocols established to protect legal minors.
Access to clearance status: Your employer agency/university/school may be able to verify your current clearance status online — BUT ONLY to check the validity of your clearance and only on the basis of details provided by you.