This is an HTML version of an attachment to the Freedom of Information request 'Documents pertaining to or giving evidence in support of wearing face masks from state or federal sources'.


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 email 
the NSWA Right to Information Officer at xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx@xxxxxx.xxx.xxx.xx  
For more information, please visit our website at https://www.ambulance.nsw.gov.au/about-us/access-to-
information/right-to-information 

1.
Your details
Surname:
 ..........................................................................................   Title:  Mr/Mrs/Ms 
Given names:
 ....................................................................................................................... 
Postal address:
 .....................................................................................   Postcode:  ............. 
Day-time telephone:   .............................................   Facsimile: ...................................................... 
Email
 ....................................................................................................................... 
I agree to receive correspondence at the above email address. 
2.
Proof of identity/consent from other persons
Proof of identity is required when an applicant is requesting personal information on their own behalf. When requesting
personal information about another person, written consent is required from that person.
  Australian driver’s licence 
  Current Australian passport 
with photograph, signature and current address
  Other proof of signature and current address details   
  Written consent provided 
3.
Government information
Please mark with an X in the boxes below what record you are seeking:
  Triple zero (000) call recording (Please note if you were not the caller you will need a signed 
authority. Please find attached authority form).    
  Incident Detail Report  
  Electronic Medical Record (eMR) 
For the above records, please indicate the time, date, location (street name/s), involved person/s, caller 
name/s (and mobile number used for triple zero calls) and any other relevant particulars in relation to the 
incident/s you are seeking information about below.  
 ............................................................................................................................................................ 
 ............................................................................................................................................................ 
 ............................................................................................................................................................ 
 ............................................................................................................................................................ 
Page 1 

Government Information (Public Access) Act 2009 
ACCESS APPLICATION FORM 
 ............................................................................................................................................................ 
  Other  
If other, 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, we may refuse to process your 
application 
Are you seeking personal information?   Yes / No  (circle one) 
4.
Form of access
How do you wish to access the information?
   A copy of the document(s) 
   Inspect the document(s) 
   Access in another way (please specify) ....................................................................................... 
 ............................................................................................................................................................ 
5. Application Fee
I attach payment of the $30 application fee by (please circle) 1. credit card (see page 4) or
2. EFT (EFT details below).
EFT Details
Westpac Bank
Sort Code/Bank Transit/BSB 032-020
Account number 228033
Swift/BIC WPACAU2S
NB: Please note NSWA GIPA in the reference section of the transaction and email the screenshot to 
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx@xxxxxx.xxx.xxx.xx
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
Your access application must be accompanied by an access application fee of $30.00 pursuant to
section 41(1)(c) of the GIPA Act.
You may apply for a 50% reduction in processing charges on the grounds of financial hardship or
special benefit to the public. If you wish to apply for a discount, please indicate the reason below:
Financial hardship – please attach supporting documentation (eg photocopy of a pension or 
Centrelink card). 
AND / OR 
Special benefit to the public – please specify why below: 
 ..................................................................................................................... …………………………… 
 ..................................................................................................................... …………………………… 
Applicant’s signature:  ........................................................................... 
Date:   .................................................................................................... 
Please email this form to: xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx@xxxxxx.xxx.xxx.xx 
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        excellence in care 
Credit Card Payment Form 
Government Information (Public Access) Act 2009 
 _ 
This form is to be completed when paying by Credit Card for access to information under the provisions of 
the Government Information (Public Access) Act (GIPA Act). 
You must submit this form with your application. 
APPLICANT DETAILS 
First & Other Name(s) 
Last Name 
Business Name (if applicable) 
ABN 
Contact Phone Number 
Email address 
PAYMENT DETAILS 
 Access Application
Amount $30.00 
 Concession Holder
Amount $15.00 
(copy of concession card required)
CREDIT CARD AUTHORITY 
NSW Ambulance is collecting this information so that we can process the fees for you GIPA Act application. We will process the 
request using a secure interface with Westpac Banking Corporation, and will not disclose the information to any other third party. 

Please debit my credit card to the amount of 
(Month/Year) 
Card Type 
 Visa 
 Mastercard
Expiry Date  
Card Number  
Card Holder Name 
Card Holder Signature
Date 
For office use only 
Application Reference No. 
Application Date 
Receipt No. 
 Successful Payment     Unsuccessful payment
    Date 
Page 4 
Version: July 2021 

NOTICE OF AUTHORITY 
TO: NSW AMBULANCE 
RE: 
name of triple zero (000) caller
I, (name and address 
), give permission for NSW Ambulance to release 
the recording of the Triple Zero (000) call which I made and any record/s in relation to same call, 
under the provisions of the Government Information (Public Access) Act 2009 (GIPA Act). 
I agree that the record/s can be released to (name of person making the GIPA application) as the 
applicant for the information. 
SIGNED: 
DATE: 
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Document Outline