Freedom of Information
Application form
Your contact details
Surname
Given name(s)
Other names you may have been known by
Date of birth
Address
Postal address
(if different from above)
Email
Home phone number
Work phone number
Mobile phone number
Proof of identity
To assist the Department of Health and Human Services (the department) in making its decision to release
documents to you, please provide a
certified copy of a photo identification document, such as your driver’s licence
or passport. If your driver’s licence does not show your current residential address please provide a certified copy
of an official letter which shows your current residential address. A certified copy is a photocopy that has been
signed by an approved witness such as a pharmacist, registered medical practitioner or police officer.
If you do not have a photographic identification document, please provide certified copies of two other documents
that show your identity, such as your Medicare card, pension card or an official letter. If you are unable to provide
these documents, please contact the Freedom of Information unit on 1300 650 172 or (03) 9096 8449.
Are you an Aboriginal and/or Torres Strait Islander person?
Please mark with an ‘X’ as appropriate. For persons of both Aboriginal and Torres Strait Islander origin mark both
‘Yes’ boxes.
Are you Aboriginal?
Yes:
No:
Don’t know:
Are you Torres Strait Islander?
Yes:
No:
Don’t know:
Request details
Please provide
details of the documents you are requesting by marking the appropriate box (or boxes) below with
an ‘X’.
Wardship
Youth Justice
Housing
Child Protection
Disability
Employee
Psychiatric
Other
If you think it would be helpful please also provide detailed information (such as time frames) in order to assist the
department in processing your application. If you are requesting specific reports please provide a description of the
report/s including the date and the author.
If you need any assistance to complete this section, please contact the Freedom of Information unit on 1300 650
172 or (03) 9096 8449.
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Special requirements for child protection documents
Sections 191(1) and 209(1) of the
Children, Youth and Families Act 2005 require written consent to disclose the
identity of a reporter/notifier or a person giving confidential information during a child protection investigation.
If you were a notifier/reporter in a child protection matter, do you consent to the release
to you of documents that
would identify you as a notifier/reporter?
Please mark with an ‘X’ as appropriate.
Yes:
No:
If you are seeking documents about other people
If you are seeking access to documents about a person other than yourself, please provide their name, date of birth
and their relationship to you in the space below. You will need to provide certified copies of any documents linking
you to that person to enable you to access the documents, such as birth certificates, death certificates or
guardianship/administration orders.
Name:
Date of birth:
Relationship:
Name:
Date of birth:
Relationship:
Access to the documents
Any documents that can be released will be sent to you by registered post. They can be sent either in hard copy
paper form or in electronic form on a compact disk.
Please mark with an ‘X’ as appropriate.
Hard copy paper documents:
Compact disk (CD):
You can also view the documents at our office.
Please mark the following box with an ‘X’ if you wish to do this.
Fees and charges
Application fee
Please mark with an ‘X’ as appropriate.
I enclose payment for the $28.40 application fee:
I request that the application fee be waived. I have included a statement of how payment of the
application fee would cause me hardship:
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Access charges
A charge may apply for access to documents. If any payment is required you will be contacted by a freedom of
information officer.
How to submit your application
Hard copy applications and any required documents should be sent to:
Freedom of Information unit
Department of Health and Human Services
GPO Box 4057
Melbourne Victoria 3001
Or fill in and return it with scanned certified copies of any required documents by email to: xxx@xxxx.xxx.xxx.xx
Checklist
Have you:
Attached certified identification?
Attached payment for the $28.40 application fee OR a statement of how payment of the application fee would
cause hardship?
Given a clear explanation of the documents that you are requesting?
Attached documents to support your application to access information about other people (for example, a birth
certificate or guardianship/administration order)?
Your privacy
The Department of Health and Human Services is committed to protecting your privacy. We collect and handle
personal information in the Freedom of Information application form for the purposes of processing your
application.
To provide a service to you and meet your needs, we will share your personal information with others within the
department, such as the program area or divisional office that may hold your documents, or with our archiving
facility.
For more information on the department's privacy collection statement, please refer to the following websites:
www.dhs.vic.gov.au/privacy and www.health.vic.gov.au/privacy
To receive this form in an accessible format phone (03) 9096 8449, using the National
Relay Service 13 36 77 if required, or email xxx@xxxx.xxx.xxx.xx
Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.
© State of Victoria, Department of Health and Human Services, June 2017.
This fact sheet was created by the Department of Health and Human Services for information purposes only. It
is not a replacement for independent legal advice.
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