Government Information (Public Access) Act 2009
NSW Ministry of Health - 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/gipaa/Pages/default.aspx .
This is not the application form for medical records. Please contact your hospital, doctor or local health
district to apply for medical records. Se
e http://www.health.nsw.gov.au/lhd/pages/default.aspx to find your local
health district.
1. Your details
First name:
..........................................................................................
Title: Mr / Ms
Last name:
……………………………………………
Date of Birth: ………………………
Address line 1:
...................................................................................………………………
Address line 2:
…………………………………………………………………………………….
State:
…………………………………………….
Postcode: ………….......................
Home phone:
………………………………………..
Work phone: …………………………
Mobile number:
.................................................
Email:
.....................................................................................................................
I agree to receive correspondence at the above email address.
Organisation:
.....................................................................................................................
Type of applicant:
Member of Parliament
Media representative
Private sector
Legal representative
Patient / Former patient
Staff member/ former staff
member
Member of the public
The questions below are optional and the information will only be used for the purposes of providing better service.
Country of birth:
…………………………………..
Main language spoken: ……………………..
Aboriginal or Torres Strait Islander:
Yes / No (circle one)
Do you have special needs for assistance with this application? ...............................................
……………………………………………………………………………………………………………………….
Page
1 of
4
Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
2.
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 NSW Ministry of Health may refuse to
process your application.
• Do not use this form to apply for medical records. Apply for medical records from your doctor,
hospital or local health district. S
ee http://www.health.nsw.gov.au/lhd/pages/default.aspx
• This application is for information / documents held by the NSW Ministry of Health only.
• For documents concerning other agencies, including Local Health Districts, please apply directly to
the respective agency for processing.
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.................................................................................................................... …………………………..
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………... (If you require more space, please attach additional pages)
Type of information you are seeking:
Personal
Other
3.
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
certified copies of one
of the following documents.
*Please note that it must contain your photograph, current address and signature.
Australian driver’s licence with photograph, signature and current address
Current Australian passport
Other Identification with photograph, proof of signature, and current address details
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) .....................................................................................
.........................................................................................................................................................
Page
2 of
4
Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
5. 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)
6. Third party consent
If the information sought is of a kind that would require consultation with a third party (as required under
section 54 of the GIPA Act), your name may be disclosed to a third party.
Do you consent to this?
Yes / No (circle one)
7.
Application Fee
I attached payment of the
$30 application fee made out to
NSW Ministry of Health
by either: cheque or money order (circle one).
Applicant’s signature: ............................................................................................................
Date: ………………..…………………………………………………………………………………..
Page
3 of
4
Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
INFORMATION FOR APPLICANTS
• Please try to provide as much detail as you can to help us identify the documents you want.
• You will be contact within 5 working days after the application is received to notify you of the
agency’s decision as to the validity of your application.
Please note: An application is a not valid access application if it is an application for excluded
information of the agency, or does not comply with the formal requirements for access applications
as per section 41 of the GIPA Act.
• Identification is required for all requests for personal information.
• If you are requesting documents relating to the personal affairs of another person, on their
behalf, they must give consent. An original signed authority by the applicant is required.
• Your request will be dealt with as soon as possible and in any case within twenty working days after
it is registered. However, if an agency is obliged to conduct third party consultations, section 54 of
the GIPA Act provides for an additional 10 working days (up to a maximum of 15 working days) in
which to process the application.
• If the documents you seek are more likely to be held by another Agency, your request will
be transferred and you will be notified.
• If you are granted access, the government information you are seeking may be of interest to other
members of the public, details about your application may be recorded in NSW Ministry of Health‘s
disclosure log. This disclosure log is on the NSW Ministry of Health website at
http://www.health.nsw.gov.au/gipaa/Pages/disclosure-log.aspx
• You have a right to object to these details being included in our disclosure log, in certain
circumstances. For example, you might object if the government information you seek contains
your own personal information or concerns your business, commercial, professional or financial
interests. However, even if you do object, we may still decide to include details about your access
application in our disclosure log.
FEES AND CHARGES
Under the GIPA Act, the application fee is $30.00 which, in a request for personal documents,
covers 20 hours of processing. Processing charges for non-personal requests are $30.00 per hour.
Processing charges (not including the application fee)
may be reduced by 50% if the applicant is,
the holder of a Pensioner Concession card issued by the Commonwealth that is in force, a full-time
student, a non-profit organisation (including a person applying for or on behalf of a non-profit
organisation), or where a public interest is sufficiently demonstrated.
You may also be required to pay processing charges for this request and a statement will be given
of any such charge, if appropriate.
Please send this form
GIPA Specialist
and the application fee to:
Corporate Governance & Risk Management
Legal and Regulatory Services
NSW Ministry of Health
Locked Mail Bag 961
North Sydney NSW 2059
General information about the GIPA Act is available by calling The Information and Privacy Commission NSW on
Freecall 1800 472 679 Email:
xxxxxxx@xxx.xxx.xxx.xx Website:
www.ipc.nsw.gov.au.
Office use only: Date application received: ……………………………File reference:……………..……………………………………..
Page
4 of
4
Document Outline
