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)
Page 2
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
Page 3
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:
Page 5
Document Outline
