NDIS Worker Screening Check

OFFLINE APPLICATION

Before you begin

This NDIS Worker Screening Check form is for customers that have been
unable to complete their check online.

You must attempt to apply online before starting this offline form. You can
begin the online application by scanning this QR code.

NOTE: The processing time for the screening check is much faster when you complete it online.

Steps to complete
PART A - You must include pages 4 - 15 when mailing your application

1 Fill in your details. Read and sign declaration

2 Choose how long we save your documents

3 Tell us if you’re working for an organisation, self-managed, or volunteering

4 Referee check

5 Payment details - for student placement and paid worker checks only

PART B - Instructions on how to send us the right documents

6 Selecting your identity documents

7 Certifying your identity documents

8 Tell us how we did

9 What’s next

V19 06.2024 Page 1

 Sending your completed form and certified documents
NOTE: You do not need to send us this page.
You should use it as a guide to ensure you have provided us everything we need to process
your aplication.

Check Section 6A (page 16) or 6B (page 18) to make sure you can give us the right identity (ID)
documents before you begin this application.

If you can’t provide us with the right identity (ID) documents listed in Section 6A (page 16) or 6B
(page 18), you will be unable to complete this application.

The completed form and certified copies of your identity (ID) documents must be mailed to:

Service Victoria
Locked Bag 3040
BALLARAT VIC 3353

Checklist - Tick when completed

1. Complete all sections

2. Make sure you include the certified identity (ID) documents we need. The certified identity
(ID) documents you need to submit will depend on what you have available to give us.

If you choose the identity (ID) documents in Section 6A (page 16), you will need to give us:
• 3 certified identity (ID) documents if your name matches on all documents or
• 4 certified identity (ID) documents if you’ve changed your name

OR
If you choose the identity (ID) documents in Section 6B (page 18), you will need to give us:
• 4 certified identity (ID) documents if your name matches on all documents or
• 5 certified identity (ID) documents if you’ve changed your name

Make sure you read Section 7 (page 21). It tells you how to correctly certify your documents.

3. You should include two passport quality photos if you told us to save your identity
(ID) for 10 years

4. Make sure you send us pages 4 - 15 along with your certified identity (ID) documents.
If you want to give us feedback you can also include page 22.

! If you need to attach extra pages to your application

Make sure you label each section and page number. This helps us complete your
application quickly.

V19 06.2024 Page 2

 How to digitally sign and certify your documents

Digital signatures
The examples below show how to sign this form digitally.

Acceptable Not acceptable

If you're signing this form digitally, you must We can’t accept typing your name or initials
use your cursor or touch screen to create as the signature.
your signature.
You can also add a signature you’ve already
saved in your browser or PDF reader.

Jane Doe J.D

Certified documents

The examples below show how a certified document copy should look.
The certifier’s stamp should not cover any information on the copy.

• You must certify all documents you provide with your application
• Read Section 7 (page 21) for a list of certifiers and detailed steps on how to certifying your
documents

Certified copies can be annotated

with a stamp, and must include:
1. Writes or stamps: ‘Certified to CERTIFIED TO BE A TRUE COPY OF
THE ORIGINAL DOCUMENT I SAW
be a true copy of the original
document I saw’ NAMEJane Citizen
2. Authorised certifier name POSITIONPharmacist
ADDRESS Shop 2-G07 Exhibition St, Melbourne VIC 3000
3. Authorised certifier qualification DATE 13-11-2022

4. Personal or professional address SIGNED Jane Citizen

5. Date certified
6. Certifier signature

Certified copies can be hand-written

to say ‘Certified to be a true copy
of the original document I saw’ and
must include: Certified to be a true copy of the original document I saw
1. Writes or stamps: ‘Certified to Name: Jane Citizen
be a true copy of the original Position: Pharmacist
Address: Shop 2-G07 Exhibition St, Melbourne VIC 3000
document I saw’ Date: 13-11-2022
Signed: Jane Citizen
2. Authorised certifier name
3. Authorised certifier qualification
4. Personal or professional address
5. Date certified
6. Certifier signature

V19 06.2024 Page 3

 Reference number (Office use only)
1 Fill in your details You must include this
page when mailing us
your application.

1. You must have a Service Victoria account to complete your

application. If you don’t have an account, sign up by scanning the
QR code or go to service.vic.gov.au/account.
2. Print clearly using a black pen only.
3. Use BLOCK LETTERS and print one character in each box.

J A N E D O E C I T I Z E N
Sign up QR Code
4. Answer all questions. Fill in your details as displayed on your identity
(ID) document to avoid delays in processing your application.

Personal details
Email
H U S S A I N . S U L E M A N 9 2 2 8 @ H O T M A I L . C
O M
Use the same email as your Service Victoria account.

Phone number
0 4 5 2 3 4 9 2 2 8
We may need to contact you for more info.

Given name
H U S S A I N

Middle name/s

Family name
S U L E M A N
Only have one name? Enter it here.

Date of birth Gender

D
2 D
3 M
0 M
1 Y
1 Y
9 Y Y
9 4 Woman Man Self described

Country of birth
P A K I S T A N

State/Territory of birth

City or town of birth

F A I S A L A B A D

V19 06.2024 Page 4

 1 Fill in your details (continued) You must include this
page when mailing us
your application.

Are you of Aboriginal or Torres Strait Islander or origin?

Aboriginal Torres Strait Islander Both Prefer not to say No

Do you have a Victorian Working with Children Check (WWCC)?

No Yes: Provide your WWCC Number

Other names
We need to know all the names you go by. This includes names that you’re also known as.
e.g. If your birth name is Joseph, but you prefer Joe.

Have you ever been known by another name?

No - Go to Address on page 6
Yes - Fill in your details below

Name 1
Maiden name Also known as Previously used name

Given name

Middle name/s

Family name

Only have one name? Enter it here.

Name 2
Maiden name Also known as Previously used name

Given name

Middle name/s

Family name

Only have one name? Enter it here.

I have more than two names - include these on an extra page

V19 06.2024 Page 5

 1 Fill in your details (continued) You must include this
page when mailing us
your application.

Address
We need to know all the places you have lived in the last five years.
Start by entering your current address details.

Current home address (in Australia)

Street
G 0 1 / 5 4 - 5 6 S C O T T S T R E E T

Suburb
D A N D E N O N G

State/Territory Postcode
V I C 3 1 7 5

Is your postal address the same as your current home address?

Yes
No - Provide your current postal address in Australia below

Street

Suburb

State/Territory Postcode

Have you lived at this address for five years or more?

Yes - Go to Consent and declaration on page 8
No - Please enter every previous address you’ve lived at for the last five years on page 7

V19 06.2024 Page 6

 1 Fill in your details (continued) You must include this
page when mailing us
your application.

Previous address
If you have not lived at your current address for 5 years.
Enter every address you’ve lived at for the last five years

Previous address 1
Street address
2 / 7 C O L O N S A Y R O A D
Please include unit number if needed.

City/Town/Suburb
S P R I N G V A L E

State/Territory/Region/Province (if applicable)

V I C T O R I A

ZIP/Postcode (if available)

3 1 7 1

Country
A U S T R A L I A

Previous address 2
Street address
2 / 9 A D R I A N S T R E E T
Please include unit number if needed.

City/Town/Suburb
S P R I N G V A L E

State/Territory/Region/Province (if applicable)

V I C T O R I A

ZIP/Postcode (if available)

3 1 7 1

Country
A U S T R A L I A

I have more than three addresses - include these on an extra page

V19 06.2024 Page 7

 1 Consent and declaration You must include this
page when mailing us
your application.

I have read and understood all of the information in Appendix A - Informed consent
(page 24-26) and provide my consent and declaration.

I agree to give Service Victoria my application to get a clearance for an NDIS Worker
Screening Check.

I know I can ask to access my personal information at any time by getting in touch
with Service Victoria at service.vic.gov.au/contact/send-us-a-message or the Workers
Screening Unit at privacy@justice. vic.gov.au.

If I do not provide this information, I may not be able to complete my application for
assessment by the Worker Screening Unit.

Prices change 1 July. Forms submitted after 1 July will incur the new cost.

Your handwritten or digital signature Date

D D M M Y Y Y Y

Note: We can’t accept typed initials or names for your

digital signature. See page 3 for examples.

! Important
If you are Under 18:
If you’re under 18, we can accept this application and it will be processed by the Worker
Screening Unit. You will be contacted if you don’t have enough identification and to gain
permission from your parent/guardian.

Are you under 18?

Yes - Go to Parent/guardian permission on page 9
No - Continue on page 10

V19 06.2024 Page 8

 1 Consent and declaration You must include this
page when mailing us
your application.

Under 18 parent or guardian permission

If you are Under 18:
The Worker Screening Unit will process your application. They may contact you if you don't have
enough identity (ID) documents or to get permission from your parent or guardian.

Parent or guardian given name

Parent or guardian middle name/s

Parent or guardian family name

Parent or guardian email

Parent or guardian phone number

We may need to contact you for more info.

Parent or guardian ID details - Select one ID only

As a parent or guardian, you will need to provide a copy of your identity (ID) document.

Current Australian Passport. Current Australian Driver Licence

or Learner Permit.

Current Foreign Passport. ImmiCard.

Proof of age or photo identity card Shooters or firearms licence

issued by an Australian Government showing signature and photo (not
agency with a signature and photo. minor or junior permit licence).

Parent or guardian signature

Parent or guardian handwritten or digital signature Date

D D M M Y Y Y Y

Note: We can’t accept typed initials or names for your

digital signature. See page 3 for examples.

Note: Make sure you attach a certified copy of the identity (ID) document you have provided to us
V19 06.2024 Page 9
 2 Choose how long we save your documents You must include this
page when mailing us
your application.

Do you want us to save your identity?

We need to verify your identity when you apply for or use some of our services.
If you save your identity, you won’t need to verify it again when you use our services.

We will tie your saved identity to your online Service Victoria account.
If you don’t already have an account, we’ll email you a link to create one.

Yes, save my digital identity for 10 years No, delete my details

• You’ll need to supply two Continue to the next page

identical passport quality
photos, scan the QR code
or go to passports.gov.au/
getting- passport-how-it-
works/photo-guidelines

• Your photos need to be signed on the back

by your referee
• Your referee must write: “This is a true
photograph of (your name)”

Attach your photos below

• Do not use sticky tape to attach your

photos
• Photos must include head and shoulders

V19 06.2024 Page 10

 3 Tell us if you’re working for an organisation, You must include this
page when mailing us
self-managed, or volunteering your application.

Type of check - Please note

• If you get paid for your work, choose ‘Paid worker’.
• If you’re a student needing an NDIS Worker Screening Check for placement,
choose ‘Student placement’. You can’t apply as a Volunteer.
• If you volunteer in a risk-assessed role you don’t profit from (or from any other
NDIS provider) choose ‘Volunteer’.

✔ Student OR Paid OR Volunteer - By choosing the Volunteer option, I confirm that

• I volunteer in a risk-assessed role I do not
placement worker profit from.
• No NDIS provider pays me for other work.

If you selected either Student placement, Paid worker, or Volunteer, you must tell us about
your placement or employment below

Employer 1
Employer Type

✔ Organisation OR Self-managed participant

Business or employer name

NDIS employer ID
- -

The Employer ID may a combination of letters and numbers.

!
E.g. (4-1234-1234) or (4-AB12-CD34)
• Please ensure that the Employer or self-managed participant ID is correct. If you are unsure,
please contact your organisation or self-managed participant direct to confirm their ID.
Without the ID, we can’t process your application.
• If you’re about to change jobs, use your new employer’s details.

NDIS employer address

Street

Suburb

State/Territory Postcode

The NDIS Quality and Safeguards Commission can help if you need further assistance. Call 1800 035 544 or visit ndiscommission.gov.au

V19 06.2024 Page 11

 3 Tell us if you’re working for an organisation, You must include this
page when mailing us
self-managed, or volunteering your application.

Employer 2
Employer Type

Organisation OR Self-managed participant

Business or employer name

NDIS employer ID
- -

The Employer ID may a combination of letters and numbers.

!
E.g. (4-1234-1234) or (4-AB12-CD34)
• Please ensure that the Employer or self-managed participant ID is correct. If you are unsure,
please contact your organisation or self-managed participant direct to confirm their ID.
Without the ID, we can’t process your application.
• If you’re about to change jobs, use your new employer’s details.

NDIS employer address

Street

Suburb

State/Territory Postcode

I have more than two employers - Include these on an extra page

The NDIS Quality and Safeguards Commission can help if you need further assistance.
Call 1800 035 544 or visit ndiscommission.gov.au

V19 06.2024 Page 12

 4 Referee check You must include this
page when mailing us
your application.

The referee makes sure you are who you say you are.
A certifier can also be your referee if they’ve known you for 12 months.
They also can’t be in a relationship with you, live with you or be related to you.

The following section is to be filled in by the referee.

You are a referee for the applicant so we can make sure they are who they say they
are. By continuing, you agree to let us check the information from your ID with the
document issuer or official record holder.

Referee given name

Referee middle name/s

Referee family name

Date of birth Phone number

D D M M Y Y Y Y
We may need to contact you for more info

Referee ID details: Select one ID only

Current Driver Licence or Learner Permit
Fill in your details on page 14

Current Australian Passport (or expired less than three years)

Fill in your details below

Current Australian Passport

Referee given name on Australian Passport

Referee middle name/s on Australian Passport

Referee family name on Australian Passport

Passport number Passport expiry date

D D M M Y Y Y Y

V19 06.2024 Page 13

 4 Referee check You must include this
page when mailing us
your application.

Current Driver Licence or Learner Permit

Referee given name on driver licence or learner permit

Referee middle name/s on driver licence or learner permit

Referee family name on driver licence or learner permit

Licence number State Licence expiry date

D D M M Y Y Y Y

Licence card number

If you need help finding your card number
!
Scan the QR code or go to
service.vic.gov.au/find-services/transport-and-
Your card number is different to your Driver driving/licences/driver-licence-card-number
Licence number. In Victoria your card
number is on the back of your card.

Confirm and sign

I confirm that:
• I’m an Australian citizen aged 18 or older.
• I’ve known the applicant for at least 12 months.
• I’m not related to, or in a relationship with the applicant.
• I don’t live with the applicant.
• I have a current Australian driver license or learner permit. Or an Australian passport
that is current or expired for less than three years.
• The following information is true and correct. I understand that there are penalties, including
up to 10 years in prison, for making, using and copying false and misleading documents.
• The documents belong to the applicant and I have seen the certified copies
provided by the applicant.

Referee handwritten or digital signature

Date
D D M M Y Y Y Y

Note: We can’t accept typed initials or names for your

digital signature. See page 3 for examples.

We’ll handle your identity information under the Service Victoria Act 2018 and our privacy and
security policy. Visit service.vic.gov.au/privacy-and-security for more information.

V19 06.2024 Page 14

 5 Payment details - student placement and You must include this
page when mailing us
paid work only your application.

Please check that your payment details are accurate. If your details are wrong or incomplete,
there will be a delay in processing your application.

We will destroy your payment details after this process.

NOTE: Go to the Service Victoria website at service.vic.gov.au to confirm current costs.

The cost is $131.60 for a student placement or paid worker check.

We don’t accept:
If you apply as a volunteer but aren’t eligible, the Worker Screening Unit • American
may contact you about paying for your screening. For example, if you’re a Express
student who needs a check to do placement, you can’t apply as a volunteer. • money orders
• cash
NOTE: The current cost is valid until 30 June 2025. We’ll charge you an • cheques
updated amount if this form is processed after 30 June 2025.

Select your payment method. A credit card fee may apply

Visa OR Mastercard

Name as it appears on card

Card number

Expiry date CVV

M M Y Y Y Y
Three - digit code on the back of your card.

For internal use only

Applicant name

Applicant number Date payment taken

D D M M Y Y Y Y

V19 06.2024 Page 15

 6A Selecting your ID documents

You must give 3 certified copies of documents in total.

At least one must be from Group A.

If you are unable to give 3 documents from Group A and B, go to section 6B on page 18.

If your name on one of the documents from Group A and B don’t match, give a fourth
document from Group C.

3 TOTAL Group A. Photo identity documents. Choose 1 or more

Australian Driver Licence or Learner Permit

Copy both front and back. Your licence number must be visible

If you need help finding your card number

!
Scan the QR code or go to
service.vic.gov.au/find-services/transport-and-driving/licences/driver-licence-card-number

Australian Passport
Current or less than three years expired

Foreign Passport with Australian Visa

Must also include a copy of your valid Australian Visa

ImmiCard

Group B. Other identity documents

Medicare Card

Australian Birth Certificate

A full copy showing the Births, Deaths and Marriages logo or your
state government. Your certificate must show a
registration number

Australian Citizenship Certificate

Copy both front and back. Your parent's certificate can be used if
your name is on it

V19 06.2024 Page 16

 6A Selecting your ID documents (continued)

Choose one document from Group C, if any of the names on your documents don’t match.

If your name doesn’t match all of the documents from group A and B, add one document
from the list below.

Group C. ONLY required if your names don't match. Choose 1

Change of Name Certificate

Australian Marriage Certificate

Your certificate must show a registration number and be issued
after your wedding day

! What happens if you don’t have these documents?

Don’t worry, you can still apply. You’ll need to send us this form with 4 certified
documents from the list of substitute documents on pages 18-20.

V19 06.2024 Page 17

 6B Selecting your ID documents (continued)
If you can’t give three copies of documents from section 6A, you must give four
documents from section 6B.

At least one of the documents you give us from the Document 1 or Document 2 lists
must have your photo on it.

If your name on one of the documents doesn’t match, give a fifth document from
the list on page 20.

Document 1 Document 2
You must supply at least 1 Commencement of Any from the list of Document 1 that you haven’t
Identity Document from the Document 1 list below. chosen already, or:

Australian birth certificate (full document, Australian marriage certificate issued by

not an extract or birth card) a state or territory (church or celebrant-
issued certificates are not accepted)
Current, valid Australian passport
Australian Government proof of age or
Australian visa current at the time of entry photo identity card (with signature and
to Australia photograph)

ImmiCard Foreign passport with a valid entry stamp

or visa
Certificate of identity issued by DFAT
Shooters or firearms licence showing
signature and photo (not minor or junior
Document of identity issued by DFAT
permit licence)
Certificate of Evidence of Residence Australian drivers' licence or learner
Status (CERS) permit

Australian citizenship certificate

If you need help finding your card
number
Scan the QR code or go to
service.vic.gov.au/find-services/transport-and-
driving/licences/driver-licence-card-number

! Under 18 years of age?

If you’re under 18 and don’t have anything
from the Document 2 list, you can use your
current student identification card with a
signature or photo.

V19 06.2024 Page 18

 6B Selecting your ID documents (continued)
Document 3 + 4 (select any 2)
Any from the list of Document 1 or Document 2 that you haven’t chosen already, or:

Certificate of identity issued by DFAT Australian secondary or tertiary student

identification document
Document of identity issued by DFAT
Certified academic transcript from an
United Nations Convention travel Australian university
document issued by DFAT
Trusted referees report (a letter or
Foreign government issued documents declaration from a trusted source,
Note: Police checks cannot be accepted including a General Practitioner,
pharmacist, or the principle of the
Medicare card
applicant's school, on a company
letterhead, and validating the applicant's
Enrolment with Australian Electoral
relationship to this source)
Commission

Security guard/crowd control photo Bank card, credit card or bank statement
licence (without payment card number/s; cannot
be American Express or Diners Club card)
Centrelink or Veteran's Affairs card
State/territory government rates
Consular photo identity card issued by assessment notice or Australian Taxation
DFAT Office assessment notice

Police officer photo identity card Australian utility bill with name and
address
Australian Defence Force photo identity
card Australian Private Health Insurance Card

Working with Children or Vulnerable Australian Trade Association card

People card or government issued
occupational licence, with photo Physical Keypass ID card issued by
Australia Post
Aviation Security Identification card We will only accept a physical Keypass ID card issued
by Australia Post on or before 31 July 2023.

Maritime Security Identification card

Credit reference check

V19 06.2024 Page 19

 6B Selecting your ID documents (continued)
If your name is not the same on all the documents from section 6B, add one document
from the list below.

Document 5
ONLY required if any of the names on your documents don't match your application form

Australian Marriage Certificate

Issued by a State Registry of Births, Deaths and Marriages

Name Change Certificate

Issued by a State Registry of Births, Deaths and Marriages

Deed poll

Divorce papers that show both names

V19 06.2024 Page 20

 7 Certifying your documents

How to certify your documents:

You must certify all documents you provide with your screening check. See page 3 for examples.

Certifying your documents with an Who is authorised to certify a document?

authorised certifier
• Accountants
Copy • Architects
1 Make copies of your original selected • Bank employees (more than 5 years of
documents - refer to section 6A or 6B.
service)
Find your certifier • Chiropractors
2 Find an authorised certifier and book • Conveyancers
a time to meet. See a list of who can • Dentists
certify on the right or visit • Engineers
justice.vic.gov.au/certifiedcopies
• Financial advisors or planners
Take your original documents and • Justices of the Peace
3 copies to your meeting • Legal practitioners
Your authorised certifier signs and • Local mayor or councillors
dates on each page: • Marriage celebrants
• Writes or stamps: ‘Certified to be a • Ministers of religion
true copy of the original document
• Medical practitioners
I saw’
• Midwives
• Authorised certifier name
• Authorised certifier occupation • Nurses
• Personal or professional address • Optometrists
• Date certified • Pharmacists
• Certifier signature • Physiotherapists
• Police officers
Referee
4 Your referee must see your certified
• Public servant (more than 5 years of
ID before signing and dating your form. service)
• Teachers
Send
• Vets
5 Send the completed form and certified
copies of identity to:
For a full list, go to
Service Victoria
www.justice.vic.gov.au/certifiedcopies
Locked Bag 3040
BALLARAT VIC 3353

V19 06.2024 Page 21

 8 Tell us how we did This page is optional
You can send us this
page if you want to
give us feedback.

Select/Tick one option

Good Bad

Tell us why (optional)

We’d love to hear your thoughts, concerns and suggestions so we can improve.
In particular, if you attempted to complete this application online but couldn’t
complete it online, we’d love to know why. Thank you.

How long did this application take to complete?

Minutes

V19 06.2024 Page 22

 9 What’s next

After you apply

Your employer or self-managed NDIS participant will have 30 days to verify your application and
confirm that you currently work (or intend to work) for them through the Commission’s National
Worker Screening Database (NWSD). If your application is not verified it may be withdrawn.

After your application has been verified it can take up to 3 weeks for us to assess your application.
In most cases, this will be a much shorter period (for example, if there is no criminal
history to assess).

However, if there is a need to assess information, it may take up to 3 weeks for us to assess an
application. This time may be extended if:
• an employer takes longer to verify an applicant’s engagement with them
• you have a common name
• a criminal history record or a finding has been made against you by a relevant disciplinary or
regulatory entity.
• you lodge a manual application directly to the Worker Screening Unit

You cannot work in an NDIS risk assessed role until you have received an NDIS Clearance, unless
you are subject to a transitional arrangement.

If your check is successful

You will receive an email to advise that you have been given an NDIS Clearance. Your NDIS
Clearance status will be recorded on the NDIS Commission’s National Worker Screening
Database (NWSD).

You will not receive a card or certificate. Your employer can check the status of your NDIS
Clearance on the NWSD at any time. Registered NDIS providers are required to link workers to
their organisation through the NDIS Commission portal.

An NDIS Clearance is valid across Australia for 5 years unless it is surrendered or revoked.

Your Clearance may be suspended or revoked if you are charged with or found guilty of a relevant
offence, or if an adverse finding is made against you by a relevant disciplinary or regulatory entity.

How long will it take?

• The entire check can take up to 8-12 weeks.
• We can’t complete your check if you don’t supply all certified documents as asked.
• Information on how to keep your details up to date can be found here
vic.gov.au/ndis-worker-screening-check

We handle your identity information following the Service Victoria Act 2018 and privacy and
security policy. Read it online at service.vic.gov.au/privacy-and-security

V19 06.2024 Page 23

Appendix A
Important notice: Informed consent

To determine your eligibility for a National Disability Insurance Scheme Clearance or a Working with Children Clearance
under the Worker Screening Act 2020 (VIC), we need to get your informed consent to the matters specified in this form.

Your informed consent means you have read and understood the information provided in this form about how your
personal information and any information obtained from Australian police agencies relevant to you will be handled and
disclosed and that you understand what you are consenting to including:
a. that you provide your permission for us to collect, share, copy and process the information in your Application and
attachments (including your personal information) in certain ways set out in this form;
b. provide your permission for us to request a nationally coordinated criminal history check on your behalf (police
record check); and
c. provide your permission for the disclosure of information.

It is important that you read this form in its entirety and, where required, get clarification to ensure your complete
understanding. You must then sign and submit this form to give your informed consent.

1. I consent to the Worker Screening Unit of Victoria (the unit) of GPO Box 1915, Melbourne Victoria 3001, its agents,
contractors and their subcontractors receiving, sharing, copying and processing the information in this Application
and its attachments for the purposes of the Worker Screening Act 2020 (VIC) (the Act), the Worker Screening
Regulations 2020 (VIC) (the Regulations) and any other relevant law. I acknowledge that the information I have
provided includes personal and sensitive information and I have provided documents to verify my identity.
2. For the purposes of this Consent and Declaration;
a. ‘NDIS’ means National Disability Insurance Scheme;
b. ‘WWC’ means Working with Children;
c. ‘Application’ means an Application under the Act for an NDIS check to be carried out and an NDIS Clearance to
be given on completion of the NDIS check or an Application under the Act for a WWC check to be carried out
and a WWC Clearance to be given on completion of the WWC check as applicable;
d. ‘Clearance’ means an NDIS Clearance or a WWC Clearance given under the Act as applicable; and
e. ‘Exclusion’ means an NDIS exclusion or a WWC Exclusion given under the Act as applicable where the unit
refuses to give me a Clearance.
f. ‘Spent Convictions Legislation’ means Part VIIC of the Crimes Act 1914 (Cth); Part 8 of the Sentencing Act
1991 (VIC), Criminal Records Act 1991 (NSW); Criminal Law (Rehabilitation of Offenders) Act 1986 (QLD); Spent
Convictions Act 2009 (SA); Spent Convictions Act 1988 (WA); Criminal Records (Spent Convictions) Act 1992 (NT);
Spent Convictions Act 2000 (ACT); and Annulled Convictions Act 2003 (TAS).
3. For the purposes of my Application and enquiries while I hold a Clearance, I authorise the conduct of a nationally
coordinated criminal history check delivered by the Australian Crime Commission (ACC) and Australian police
agencies (‘police record check’) and I provide the following consent and authorisation:
a. I consent to the unit making enquiries and seeking information about me from any source considered
necessary, including any Australian Police agency, ACC, any employee within the meaning of the Public
Administration Act 2004 (Vic), authorised entity, court, prosecuting authority, authorised screening agency
in any Australian state or territory, professional registration board, commission, commissioner, disciplinary or
regulatory entity, relevant prescribed body, health treating professional, government department or agency
including without limitation, the Director of Public Prosecutions (DPP), the Department of Health (DoH), the
Department of Families, Fairness and Housing (DFFH), the Commission for Children and Young People (CCYP),
Corrections Victoria, the Disability Worker Registration Board, the Victorian Disability Worker Commission, the
Victorian Disability Worker Commissioner and the Victorian Institute of Teaching; and
b. I authorise and consent to the disclosure of information about me and my Application (including any
information obtained from other sources as a result of making enquiries and seeking information about me)
and the outcome of my Application by the unit to any person or organisation considered necessary, including
any Australian police agency, any authorised screening unit or agency including without limitation, any unit or
agency in another Australian state or territory that provides for screening of persons engaged in child-related
work, ACC, any court, prosecuting authority, professional registration board, disciplinary or regulatory entity,
relevant entity or prescribed body, health treating professional and any government department or agency
including without limitation, DPP, DoH, DFFH, CCYP, Corrections Victoria, the Disability Worker Registration
Board, the Victorian Disability Worker Commission, the Victorian Disability Worker Commissioner and the
Victorian Institute of Teaching.
4. I acknowledge that the information which may be disclosed to the unit includes, but is not limited to:
a. details about or circumstances relating to, convictions, findings of guilt and charges (including any police
record check regardless of the outcome of the charges or when and where the offence or alleged offence
occurred;
b. details about or circumstances relating to involvement of DoH and/or DFFH with respect to child protection or
family violence; and
c. information in relation to an application made by me in another Australian state or a territory under a law of
that state or a territory that provides for screening of persons engaging in child-related work or screening of
persons who are employed or engaged in risk assessed roles providing support or services to persons with a
disability and any decision made or clearance or registration granted to me with respect to that application.

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5. I acknowledge that I understand that my personal information may be provided to police agencies for general law
enforcement purposes, including those purposes set out in the Australian Crime Commission Act 2002 (Cth).
6. For the purposes of an application or reassessment of an application made by me in another state or territory for
any clearance required at law to engage in child-related work or to provide support or services in a risk assessed
role to persons with a disability in that state or territory, I consent to the disclosure of information about me and my
Application to any government department or screening agency in that other Australian state or territory.
7. With respect to the police record check, I acknowledge that:
a. the unit is collecting my personal information to provide to ACC and police agencies to check if I have a
criminal history and to assess whether I should be permitted to work or care for children or provide support or
services to persons with a disability under the NDIS;
b. I am aware that I am providing consent for a police record check on a national basis to be conducted using all
personal information provided by me including information provided in identity documents I have supplied;
c. the unit provides information to ACC with respect to any decision made in relation to my Application or any
reassessment of my eligibility to hold a Clearance;
d. ACC discloses my personal information to Australian police agencies;
e. the information released as part of the police record check is done so in accordance with Spent Convictions
Legislation and information release policies subject to any exclusions that apply;
f. Australian police agencies may disclose to ACC information from their records and details of convictions and
charges including findings of guilt or the acceptance of a plea of guilty by a court. The information is disclosed
in accordance with applicable laws of the Commonwealth, states and territories and policies of the police
agency concerned;
g. ACC provides the information disclosed by Australian police agencies to the unit in accordance with the laws of
the Commonwealth;
h. any information provided in my Application is provided to ACC for the purpose of obtaining the Clearance or
reassessing my eligibility to hold a Clearance;
i. any information provided to the unit by Australian police agencies or ACC is provided for the purpose of
assessing my eligibility to be given or continue to hold a Clearance;
j. the Chief Commissioner of Police must take all reasonable steps to ensure that an interstate or territory NDIS
or WWC screening unit is notified of how a charge against me has been finally dealt with if that interstate or
territory screening unit has requested the notification;
k. the information I provide as part of my Application and the information which ACC provides to the unit, will
be used only for the purposes stated above unless statutory obligations require otherwise or subject to any
disclosure permitted at law or to which I have consented; and
l. if I do not agree with the results of my police record check, I will contact the Worker Screening Unit in the first
instance to advise them that I want to dispute the result by email sent to NDISworkerscreening@justice.vic.gov.
au. The Worker Screening Unit will accept and escalate all disputes.
8. If the CCYP notify the unit at any time of a finding of reportable conduct against me pursuant to 16ZD of the Child
Wellbeing and Safety Act 2005 (VIC), I consent to the unit notifying CCYP of the outcome of any Application or
reassessment of my eligibility to engage in child-related work. If I am given an Exclusion and make an application
to the Victorian Civil and Administrative Tribunal for review of the decision to give me an Exclusion, I consent to the
unit notifying CCYP that I have made such an application.
9. I understand and acknowledge that:
a. the Act and Regulations require the unit to collect my personal information and the unit to make certain
enquiries and arrange for the conduct of a police record check except in limited circumstances;
b. the consequence of non-compliance or withdrawal of my consent is that my Application will not be processed;
c. it is an offence to provide false or misleading information in a material particular in relation to an Application
for a Clearance or in connection with a re-assessment of eligibility to hold a Clearance, subject to a maximum
fine equivalent to 240 penalty units or a 2 year maximum term of imprisonment or both;
d. it is an offence to apply for a Clearance if I am subject to an order under the Sex Offenders Registration Act
2004 (VIC) or Serious Offenders Act 2018 (VIC) liable to a maximum fine equivalent to 240 penalty units or a 2
year maximum term of imprisonment;
e. while my Application is being assessed:
A. there are only very limited circumstances under the Act that I may engage in or apply for child related
work or work in a risk assessed role providing support or services to persons with a disability;
B. I am prohibited from engaging in paid or volunteer child-related work or working in a risk assessed role
providing support or services to persons with a disability if I have been charged with or found guilty of
certain charges, offences or orders specified in the Act or if I am excluded from doing child-related work or
providing support or services to persons with a disability in another Australian state or territory. If I am so
prohibited, I consent to the unit notifying the organisations whose details I have provided to the unit that
I am prohibited from engaging in paid or volunteer child-related work or working in a risk assessed role
providing support or services to persons with a disability as applicable and the Worker Screening website
will indicate that I am so prohibited; and
C. if I engage in or apply for child-related work or work in a risk assessed role providing support or services to
persons with a disability in breach of the Act, it is an offence subject to a maximum fine equivalent to 240
penalty units and 2 years imprisonment or both;
f. in accordance with the Act and the Regulations, the unit may disclose personal information about me, my
Application and any decision made with respect to my Application to the organisations whose details I provide
to the unit, or where otherwise permitted by any act or regulations;
g. I must notify the unit within 21 days of any change to my details by updating my details in the online portal
of the Worker Screening website or directly through my Service Victoria account. This includes my personal
and contact details and the details of all organisations where I do child-related work or providing support or
services to persons with a disability under the NDIS in a paid or unpaid capacity;

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 h. the Act requires me to notify the unit and any organisations where I work or care for children or provide
support or services to persons with a disability under the NDIS within 7 days of any relevant change in my
circumstances, including the following:
A. if I am charged with, convicted of or found guilty of certain offences;
B. if I become subject to reporting obligations imposed by Part 3 of the Sex Offenders Registration Act 2004,
a supervision order, detention order or an emergency detention order under the Serious Offenders Act
2018;
C. if a relevant disciplinary or regulatory finding is made against me;
D. where I am applying for or have a current NDIS Clearance, if I have been or am given a WWC Exclusion; or
E. where I am applying for or have a current WWC Clearance or hold a current WWC Clearance, if I have been
given an NDIS Exclusion or I am excluded from child-related work under a law in another state or territory;
i. I agree to notify the unit within seven days in the following circumstances:
A. if I am or have been excluded from providing support or services to persons with a disability in another
Australian state or territory;
B. if I am or become subject to a banning order under section 73ZN of the National Disability Insurance Act
2013 (Cth); or
C. where I am applying for or have a current NDIS Clearance, if I have been excluded from child-related work
under a law in another Australian state or territory and
j. where I am applying for or have a current NDIS Clearance:
A. the NDIS Quality and Safeguards Commission (NDIS Commission) will use the NDIS Worker Screening
Database (NDIS Database) to undertake its statutory functions under the National Disability Insurance
Scheme Act 2013 (Cth);
B. NDIS worker screening units are authorised under legislation to provide my personal information to the
NDIS Commission for the purposes of the NDIS Commission undertaking its statutory functions in relation
to the NDIS Database; and
C. my information will continue to be included in my record on the NDIS Database even if I no longer work in
the NDIS sector and NDIS employers will be able to access information about me on the NDIS Database
(unless they are no longer linked to me).
10. I consent to the unit correcting the contact information of the organisations for which I do child-related work or
provide support or services to person with a disability under the NDIS, if it is satisfied that the information held is
incorrect.
11. I consent to the unit sending all communications to me and serving all notices upon me under the Act and the
Regulations by email to the email address provided by me to the unit at the time of making my Application or
subsequently notified by me to the unit by updating my details through the online portal of the Worker Screening
Unit (the online portal) or directly through my Service Victoria account. This includes the communications and
notices:
a. requesting information (including any document, written submission or consent) for the purposes of assessing
or completing my Application or if I am issued with a Clearance, re-assessing my eligibility to hold a Clearance;
b. notifying me about the finalisation, progress and outcome of my Application;
c. contacting me about updating my details;
d. if I am issued with a Clearance, reminding me about the expiry of my Clearance, notifying me of any re-
assessment of my eligibility to hold a Clearance, the progress and outcome of such re-assessment or the
revocation, suspension or cancellation of my Clearance and sending me periodic emails and eNewsletters; and
e. sending me requests for feedback.
12. Except for providing information about changes to my profile information and email address which I agree to
provide to the unit through the online portal of the Worker Screening website or directly through my Service Victoria
account, I agree to send all written communications (including notifications, correspondence and documents) to
the unit by email sent to the Worker Screening Unit at NDISworkerscreening@justice.vic.gov.au and I acknowledge
that sending all written communications by email to that email address is a requirement of the unit in order to
assess my Application or, if I am granted a Clearance, to re-assess my eligibility to hold a Clearance.

I declare that:
1. I am the applicant named in my Application, and that all information and documents provided as part of my
Application are true, complete and correct.
2. I have not omitted any names or aliases that I am currently known by or have ever been known by in the past.
3. If I have provided a photograph for the purposes of this Application, that photograph is less than 12 months old.
4. I acknowledge that withholding information or providing false or misleading information in any of the details and
documents provided as part of my Application is a serious offence and may lead to prosecution. If I become aware
that I have provided incomplete, incorrect or misleading information, I will contact the Worker Screening Unit as
soon as possible.
5. I have read and fully understand the information provided in this form about how and for what purposes my
personal information and any criminal history information relevant to me will be handled and disclosed and I
understand what I am consenting to.
6. I acknowledge that any information sent electronically (including online or by email) is sent at my risk and I am
aware of the consequences of sending information in this way.
7. I understand that I may withdraw any consent given as part of this consent and declaration by written notice
emailed to the Worker Screening Unit sent to the email address specified in paragraph 12 above. However, if
I withdraw my consent to a national police record check or any other consent included in this consent and
declaration, the unit will withdraw my Application and if I have already been issued with a Clearance, I will surrender
it. I understand that if I surrender my Clearance, the unit may still assess my eligibility to have a Clearance.
8. I understand by applying as a volunteer I am declaring that I volunteer in a risk-assessed role and do not obtain any
profit or gain from doing so. If I incorrectly apply as a volunteer, the WSU may contact me for payment.

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