Government Information (Public Access) Act 2009
ACCESS APPLICATION

Please complete this form to apply for formal access to government information under the Government
Information (Public Access) Act 2009 (GIPA Act).  If you need help in filling out this form, please contact
the Right to Information Officer, NSW Ministry of Health, on 9391 9263 or visit our website at
http://www.health.nsw.gov.au/
1.
Your details
Surname:
............................................................................................   Title: Mr / Ms
Other names:
.....................................................................................................................
Postal address:
...................................................................................   Postcode:  .............
Day-time telephone:   ............................................   Facsimile: .....................................................
Email:
.....................................................................................................................
    I agree to receive correspondence at the above email address.
2.
Proof of identity
Only required when an applicant is requesting information on their own behalf.
When seeking access to personal information, an applicant must provide proof of identity in
the form of a certified copy of any one of the following documents:
  Australian driver’s licence
  Current Australian passport
with photograph, signature and current address
  Other proof of signature and current address details
3.
Government information
Please describe the information you would like to access in enough detail to allow us to identify it.
Note: If you do not give enough details about the information, the agency may refuse to process your
application.
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Are you seeking personal information?   Yes / No  (circle one)
[H12/49559-11] Access Application Form - April 2014.doc
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Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
4.
Form of access
How do you wish to access the information?
Inspect the document(s)
A copy of the document(s)
Access in another way (please specify) ......................................................................................
..........................................................................................................................................................
5.
Application Fee
I attach payment of the $30 application fee by cash / cheque / money order (circle one).
(Note: please do NOT send cash by post)
6.
Disclosure log
If the information sought is released to you and would be of interest to other members of the public,
details about your application may be recorded in the agency’s ‘disclosure log’. This is published
on the agency’s website.
Do you object to this?   Yes  / No  (circle one)
7.
Discount in processing charges
If you are given access to the information sought, you may be asked to pay a charge for
processing the application ($30 / hour).  Some applicants may be entitled to a 50% reduction in
their processing charges.  If you wish to apply for a discount, please indicate the reason:
    Financial hardship – please attach supporting documentation (eg a pension or Centrelink
card).

AND / OR
    Special benefit to the public – please specify why below:
..........................................................................................................................................................
..........................................................................................................................................................
Applicant’s signature:  .........................................................................
Date:  ..................................................................................................
Please post this form or lodge it at: Senior External Relations Officer, Strategic Relations and
Communications Branch, NSW Ministry of Health, 73 Miller Street, North Sydney NSW 2060.

General information about the GIPA Act is available by calling the Information and Privacy Commission
freecall 1800 472 679 or at its website: http://www.ipc.nsw.gov.au
Office use only
Date application received: .............................................................................
File reference: ...............................................................................................
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Document Outline