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 filling out this form, please contact
the Right to Information Officer on Tel: 4320 3570 or Email:
xxxxxxxxxxxxxxxx@xxxxxx.xxx.xxx.xx .
1.
Your details
Surname:
………………………………………………………….
Title: Dr/Mr/Ms/Miss/Mrs
Other names:
.....................................................................................................................
Postal address:
...................................................................................
Postcode: .............
…………………………………………………………………………………………
Day-time telephone: ............................................
Mobile: ..........................................................
Email:
.....................................................................................................................
The questions below are optional and the information will only be used for the purposes of providing better service.
Place of birth:
…………………………………..
Main language spoken: ……………………..
Do you require an interpreter:
Yes / No (circle one)
Aboriginal or Torres Strait Islander:
Yes / No (circle one)
Do you have special needs for assistance with this application: ................................................
………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………..
I agree to receive correspondence at the above email address.
2.
Proof of identity
Only required when an applicant is requesting their own personal information.
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
………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………..
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Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
3.
Government information
Please describe the information you would like to access. Please be specific, for example,
timeframes, exact areas, names of documents.
Note: If you do not give enough details about the information, the agency may not be able to process your
application
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Are you seeking personal information?
Yes / No (circle one)
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).
Please make cheques and money orders payable to Central Coast Local Health District.
(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)
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Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
7.
Discount in processing charges
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
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Applicant’s signature: .........................................................................
Date: .................................................................................................
Please post this form to:
Right to Information Officer
Ministerial and Executive Services
Central Coast Local Health District
PO Box 361
Gosford NSW 2250
General information about the GIPA Act is available by calling the Information and Privacy Commission (IPC) on
1800 472 679 or visiting the IPC’s website: www.ipc.nsw.gov.au
Office use only
Date application received: ................................................................................
File reference: ...................................................................................................
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