GIPA_FORM

Government Information (Public Access) Act 2009 - Access Application

Applicant details

Before you fill in this form please read the department’s agency information guide at https://education.nsw.gov.au/aboutus/rights-and-accountability/information-access and look to see whether the information you want is already available onour website. If in doubt, contact Right to Access and ask them if the information is already available or can be made available without a formal access application under the GIPA Act.

Title

Other

Applicant Name

Applicant Surname

Street Address 1

Street Address 2

City

State

Postcode

Contact Information

Email Address *

Mobile Phone

Day time phone

I agree to the release of my/my client’s/my child’s name to any third parties the department may need toconsult as part of my application. I understand that not agreeing could affect the outcome of my application.

Requesting Information

Have you made an application for the same or similar information from another agency?

YesNo

Name of other agency

Proof of Identity and authority is required for personal information

Proof of identity is required when requesting personal information in order to comply with privacy requirements. Please provide a copy of the following documents with your application .

We require an identification document with a signature. For example:

Current Australian photo driver’s licence; or
Australian passport; or
other proof of name, signature and current address details

Proof of Identity and authority is required for personal information

Proof of identity is required when requesting personal information in order to comply with privacy requirements. Please provide a copy of the following documents with your application .

We require an identification document with a signature. For example:

Parent/carer signature ID;
ID with proof of relationship (E.g. Medicare card or birth certificate showing both parent/carer and child name);
Child’s authority form for counselling records (if over 12years old)

Proof of Identity and authority is required for personal information

Proof of identity is required when requesting personal information in order to comply with privacy requirements. Please provide a copy of the following documents with your application .

For records belonging to an adult:

Client/third party’s ID;
Client/third party’s authority

For records belonging to a child:

Parent/carer signature ID;
ID with proof of relationship (E.g. Medicare card or birth certificate showing both parent/carer and child name);
Client/third party’s authority; and
Child’s authority form for counselling records (if over 12 years old)

*You can download a blank Authority Form from here.

Name of Your Law Firm or Organisation *

Your Reference (optional)Your internal reference number to include in correspondence

Are these records:

Student records?Employment records?Complaint or Investigation records?Other?

Child's Name

Client's Name

Third party name

Date of birth

IMPORTANT

If your are requesting information about a complaint, please read the Information and Privacy Commission's guidelines about complaints information prior to making an application. We may not be able to provide you with any information about a complaint as it is likely to breach confidentiality.

Name of the last NSW government school attended ** If the last attended NSW school name is not provided your application will be considered invalid.

The last calendar year you attended a NSW Government School (not grade)* If the last attended NSW school name is not provided your application will be considered invalid. * This means the last government school attended, usually high school, in NSW. This does not mean the school you are requesting records from.

Employee Name

Employee ID

Information sought

Please be as specific as possible in your description of the information you seek. The department has limited resources to carry out the important work mandated by the GIPA Act. As a result, a broad or generic request may be considered a significant diversion of the department's resources, and your request may be refused.

Please provide me with the following information: *

Date from:

Date to:

Reason for making this application (*optional)

Payment

Applications must be accompanied by a $30 application fee (s41(1)(c) GIPA Act)

Payment can be made by following the instructions on the NSW Department of Education Right to Access web page.

Please enter your Payway receipt number:

Documents

Cover letter (optional)

Browse

Identification documents

Browse

You can upload multiple documents in this field.

Client Authority

Browse

Third party authority

Browse

Child's Authority (if over 12 years of age)

Browse

Proof of relationship document

Browse

Payment confirmation

Browse

A blank authority form can be downloaded here.

Declaration

Signature *

Draw signature|Type signatureClear

I declare that the information I have provided on this form is true and correct.

*

Privacy Notice

The information provided on this application form is being obtained for the purpose of processing your GIPA application. Providing this information is required by law. It will be stored securely. If you do not provide all or any of this information it could prevent or delay the processing of your GIPA application.

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