National Diploma in Mental Health
(Mental Health Support Work) 2016
For New Zealand Citizens & Permanent Residents
Due to the Mandatory Review of Qualifications, this qualification will soon be replaced by the
New Zealand Diploma in Health and Wellness (Mental Health), Level 5, and/or the New Zealand
Diploma in Addiction Studies, Level 6, Details relating to these qualifications are not yet available.
The National Diploma in Mental Health (Mental
Health Support Work) programme offers you
stimulating training, leading towards an advanced
qualification as a Mental Health Support Worker.
The National Diploma in Mental Health (Mental
Health Support Work) programme is designed
for people who have already developed or wish
to develop a higher level of competence and
more in-depth understanding of mental health
support work than is covered by the Certificate
level qualification in Mental Health and Addiction
Support.
These mental health support workers may have
more seniority in the workplace, carry a higher
level of responsibility, and engage in more complex
relationships with consumers/tangata whai ora. They
may also lead a team of mental health workers.
Students are required to have completed either the
National Certificate in Mental Health and Addiction
Support or the pre-requisite unit standards from
the National Certificate in Mental Health (Mental
Health Support Work) in order to enrol in this
diploma programme.
Students who have completed a course of study
equivalent to these National Certificates may apply
for RPL (recognition of prior learning) – and should
discuss this with the programme coordinator before
enrolling.
The remaining units for the National Diploma
in Mental Health normally comprise a full-time
33 week programme. This programme has a
large practicum component and on-line learning
opportunities alongside six 3-day class-room block
courses scheduled regularly though the year.
This programme is open to all people who fulfil the
entry criteria. Fees are to be paid by the individual
student. The Ministry of Health offers a training
grant to students in mental health placements/
workplaces to reimburse some of the course fees.
In this application pack you will find information on
the unit standards contained within the programme.
You are welcome to make an appointment to
discuss your study options with our staff and to
view our facilities.
EIT Hawke’s Bay
Level 6 | February | 187 credits | 33 weeks | Full-time, part-time options are available |
Campus with On-line material and support
$5,263 approximately.
Depending on courses selected fees can vary.
A $2,500.00 training grant to offset course costs is offered by the Ministry of Health
to students in qualifying mental health placements or workplaces. The programme
Coordinator can supply information about this grant and the application process.
This is a guide only. All costs quoted include GST. Fees apply to NZ Citizens and New Zealand Permanent Residents only.
Programme Contact:
Hawke’s Bay. Rita Smith Phone: 06 974 8000 ext 5079. Email: rsmith2@eit.ac.nz
EASTERN INSTITUTE OF TECHNOLOGY
0800 22 55 348 | eit.ac.nz
Te Aho a Māui
Semester One
Programme Starts
Monday, 15 February 2016
Mid Semester Break
18 April - 29 April
ANZAC Day
Monday, 25 April
Queen’s Birthday
Monday, 6 June
Semester One Ends
Friday, 24 June
Mid Year Holidays
27 June - 15 July
Semester Two
Semester Two Starts
Monday, 18 July
Mid Semester Break
26 September - 7 October
Term Four Starts
Monday, 10 October
HB Anniversary Day
Friday, 21 October
Labour Day
Monday, 24 October
Programme Ends
Friday, 25 November 2016
■■ $300 approximately for stationery and cost of personal travel to
placement locations.
Your career opportunities
ENTRY CRITERIA
In the diverse mental health and addiction
environment, support workers provide a variety
of services to clients within a range of health and
community settings.
Academic Criteria Required
NCEA Level 2
Information Session
Recommend
Yes
Police Check Required
Yes
Possible jobs and career opportunities exist within:
Health Declaration Required
No
■■
■■
■■
■■
■■
■■
■■
IELTS
6.0
Min IELTS Band
5.5
Community-based support services
Day programmes
Iwi health providers
Mental health and addiction support services
Peer support
Residential support services
Volunteer sector
TOTAL NUMBER OF CREDITS
■■ Meet the NCEA Level 2, or provide evidence of
achievement at an equivalent level.
Or
■■ Attend an information session with a member of
the academic staff and successful completion of
the alternative academic entry test.
The National Diploma consists of 187 credits.
Information session
Students who have completed the National
Certificate in Mental Health (Mental Health Support)
will have already achieved 55 credits from the unit
standards required for the Diploma.
An information session is compulsory for those who
do not meet the academic entry criteria and it is
recommended for those who do meet the academic
entry criteria. It will allow parties to exchange
information about what the programme provides for
students, and requires of students. Included will be
discussion of possible career paths for the student,
motivation, and physical and emotional requirements,
and applicant’s abilities, background, experiences and
interests. Attendance of whanau members and/or
other support people is encouraged.
Students who have completed the National
Certificate in Mental Health and Addiction Support
will be able to cross-credit the equivalent credits.
Please notify the programme coordinator to ensure
the correct cross credits are recorded.
In 20156 EIT will only be teaching the remaining
132 credits comprising the level 5 and level 6 unit
standards required for the Diploma.
Alternative academic entry assessment
The alternative academic entry assessment will
measure applicants’ literacy and numeracy ability to
ensure that it is of a level to cope with the demands of
the programme.
Professional criteria
All applicants are required to:
■■ Sign a declaration and a request for personal
information held on the Police computer.
If the declaration identifies any issue that may impact
on the student’s ability to complete the programme,
the student can discuss these with the Programme
Coordinator at an information session. EIT reserves
the right to decline entry to the programme should
an applicant’s police record be such that they would
be considered unsuitable for the type of work
undertaken whilst on this programme or by graduates
of this programme. The guidelines on which this
decision will be based are the relevant professional
association or industry requirements.
English language entry requirement
Applicants for whom English is not their first language
must have an acceptable level of English language
fluency prior to enrolment in the programme. This
may be demonstrated in a variety of ways, including
successful study of a programme in which English
was the language of instruction, completion of a New
Zealand Certificate in English Language (Level 3),
approved scores on IELTS tests (6.0 Academic with no
band score lower than 5.5), completion of accepted
international equivalents, or completion of an EIT
assessment.
Entry with credit
You may already have some knowledge or skills that
can be recognized as part of your intended study.
This may take a number of different forms including
study while at high school, study at a private training
establishment, workplace training, other tertiary study,
life experiences or voluntary work. If you think you
may qualify, you may want to apply for Cross Credit
or Recognition of Prior Learning.
■■ Cross Credit is based on the equivalency of
courses or qualifications. You would apply for
Cross Credit if you have passed a very similar
course at the same level.
■■ Recognition of Prior Learning (RPL) is based on
the assessment of your current knowledge and
skills. You would apply for RPL if you had gained
the relevant knowledge and skills through life
experiences and informal learning situations.
You will be asked to provide details of anything
that you would like considered as credit toward
your intended programme of study, as part of your
application.
A student wishing to gain credits through RPL
or Cross Credit for a course normally must have
been accepted for the programme at the time of
application for RPL.
Enquiries about RPL and Cross Credit can be directed
to Rita Smith, Programme Secretary, phone 06 974
8000, ext 5079.
Class times
6 x 3-day blocks of face-to-face classroom based
study are scheduled throughout the year. Students are
required to complete at least two days per week in a
workplace or practicum placement setting as well as
self-directed study and on-line activities. Additional
study days and tutorials will also be scheduled.
Individual Study Hours
The programme consists of a minimum of 132 credits
(1320 learning hours).
Assessments
Assessments include essays, written reports,
assignments, and practical demonstration of skills..
Academic Staff
Our lecturers are highly trained professionals with
particular areas of expertise in mental health.
Staff maintains contact with other professionals in the
health and education sectors.
We value our partnership with students and aim
to provide quality education in a supportive
environment, encouraging personal growth and
professional development.
Name
Qualification
Chris Malcolm
Programme Co-ordinator
(06) 974 8000, ext 5840
cmalcolm@eit.ac.nz
MTh (Oxford), BTheol
(Auck), BA (Victoria)
Diana Kirton
Practicum Manager,
School of Health and
Sport Science
(06) 974 8000, ext 5476
dkirton@eit.ac.nz
BA Psychology, Otago
HOW TO ENROL
STEP 1
STEP 2
STEP 3
Request an Application Pack.
This includes detailed programme
information, entry requirements,
and an enrolment form.
0800 22 55 348
eit.ac.nz
info@eit.ac.nz
Complete and return the enrolment
form and all supporting documents
outlined in your Application Pack.
You may be contacted and invited
to an interview.
You will receive an acceptance
letter with programme information
including your programme start date.
Your acceptance letter may also
include course selection forms, you
need to complete and return them.
You or your employer will receive
an invoice.
Organise payment of your fees.
DISCLAIMER: There is a nationwide transition to new New Zealand qualifications at Levels 1-6. Information contained in this publication is correct
at the time of printing, but may be subject to change. Whilst all reasonable efforts will be made to ensure listed programmes are offered and
regulations are current, EIT reserves the right to change content, method of delivery, to withdraw any programme or course of study, or impose
limitations on enrolment. Some programmes mentioned in this publication are subject to final approval and accreditation or sufficient enrolments
being received. Fees for 2016 will be set by EIT Council by November 2015 and are subject to change.
Check eit.ac.nz for the latest information or phone 0800 22 55 348.
WORLD CLASS ‘A’ RATED LECTURERS
EIT lecturers have the latest knowledge and research
in their field of expertise, and are able to attract
all-important research grants. For you, it means highly
qualified academics who have the most up-to-date
learning available.
EIT is rated one of the top two institutes of
technology and polytechnics in New Zealand for
research excellence by the Tertiary Education
Commission. This helps EIT secure funding through
the Government’s performance-based research fund.
Government funding helps EIT continue to play a
leading role in research in New Zealand.
Our lecturers are in demand to work closely on
research projects with universities, polytechnics,
businesses and organisations at regional, national and
international levels. They pass on their knowledge to
you via their teaching. When you study at EIT, you
will be at an institute that is highly rated for quality
academic research.
Student Finance
STUDYLINK
StudyLink is a service of the Ministry of Social
Development. It administers Student Allowances
and Student Loans as well as other forms of financial
assistance for students.
The StudyLink website provides tools, calculators and
information to help students who are thinking about
study to plan their finances and only borrow what
they need.
Use StudyLink’s ‘What You Can Get’ eligibility test to
find out what you may be eligible for.
STUDYLINK on 0800 88 99 00 or online at
www.studylink.govt.nz
COURSE DESCRIPTIONS
NB: Courses are offered subject to sufficient numbers applying.
CORE / Compulsory Courses
No. of
Credits
NZQA
Level
Semester
Offered
Support a mental health consumer/tangata whai ora in
their management of alcohol and/or other drugs
12
6
Full year
US 19750
Provide support to families/whānau in mental health
support work
15
6
Full year
US 20043
Support mental health consumers/tangata whai ora to
access employment support services
12
6
Full year
US 22833
Support a consumer/tangata whai ora to achieve a
recovery goal in mental health support work
15
6
Full year
US 22834
Analyze discrimination and implement an individual
advocacy strategy in mental health support work
9
6
Full year
US 22835
Implement a strategy to respond to discrimination
against consumers/tangata whai ora
15
6
Full year
US 22836
Analyze the application of ethical values for mental
health support work
6
6
Full year
US 22837
Demonstrate an integrated theory for mental health
support work
15
6
Full year
US 22838
Analyze legal structures and laws for mental health
support work
6
5
Full year
US 22839
Analyze leadership and lead a group or team to
achieve mental health support work objectives
6
5
Full year
US 22840
Critique and interpret a research project relevant to a
mental health service user group
9
5
Full year
US 22841
Explain and apply knowledge of human development
and health issues in mental health support work
12
6
Full year
Course No
Brief Description
US 18547
Practicum, Work Experience
Practical work experience in mental health organizations forms an integral part of the Eastern
Institute of Technology (EIT) Diploma in Mental Health (Mental Health Support Work).
Students often regard their student placement as a key part of their learning experience.
NATIONAL DIPLOMA IN MENTAL HEALTH (MENTAL HEALTH SUPPORT WORK) 2016
DOCUMENTATION / FORMS
Please Note
The following documents need to be completed and returned
with your application/enrolment to the School of Nursing
Administration Office.
Without these documents we are unable to proceed with your
application
• Brief Personal Statement including Brief CV/Work History
• Consent to Disclosure of Information (Vetting Service Request and Consent Form) - Please ensure you
provide two verified forms of ID, one of which must be photographic, for your vetting application
NATIONAL DIPLOMA IN MENTAL HEALTH (MENTAL HEALTH SUPPORT WORK) 2016
BRIEF PERSONAL STATEMENT
Please also include a brief CV/Work History
Name:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
1. What do you believe are your personal strengths?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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2. How would you describe your attributes as a friend, a family member, or as a member of your community ?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. Why are you interested in studying for a qualification in mental health support?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. If you have worked/volunteered within this industry, please describe your experience and the number of hours involved.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5. As part of this programme you may have practical experiences with agencies or organisations that may require you to obtain a
police vet of your personal information for any criminal convictions, criminal history, and details of fines and enforcements.
Have you ever had a criminal conviction?
Yes
No
A prior conviction may not necessarily exclude you from acceptance into the programme, but we may need to discuss it with you.
6. If you have any health or disability issues that may affect your ability to successfully complete this programme, that could affect
your safety or those for whom you are providing care, please outline this:.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7. If you care for dependents or others and this may affect your ability to successfully complete the programme, please explain the
nature of this and how it may affect your study.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Sign:
Date:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________
NZPVS‐CS ‐ 07/15 Vetting Service Request and Consent Form
Section 1: Approved Agency to complete
Name of Applicant to be vetted: Name of Approved Agency submitting vetting request: New Zealand Police Vet only Sections 1 & 2 to be completed New Zealand Police Vet & Australian National Police History Check Sections 1 ,2 & 3 to be completed APPLICANT’S ROLE – PURPOSE OF VET Employee Contractor/Consultant Volunteer Prosecution Vocational Training Licence/Registration Visa/Work Permit Other: (please specify here) Description of Applicant’s role / licence / registration (e.g. caregiver; cleaner; taxi driver; teacher; etc): Student What group(s) will the applicant have contact with in their role for your agency? Children/Youth Elderly Other Vulnerable Adults Other: (please specify here) What is the applicant’s primary role for your agency? Care & Protection (Children/Youth) Care & Protection (Elderly/Vulnerable Adults) Healthcare Other (please specify here) Education Is this request mandatory under the Vulnerable Children Act 2014 (VCA)? Yes( VCA Core Worker) Yes( VCA Non‐Core Worker) No (mandatory under other legislation/optional/standard Police Vet) Please note the NZ Police Vetting Service cannot provide any guidance as to whether requests are subject to the Vulnerable Children Act 2014. For information on this please see www.childrensactionplan.govt.nz. If this is a mandatory Vulnerable Children Act request, please specify the check reason below: New Children’s Worker: Applicant is working for the first time in your organisation in a children’s worker role. Existing Children’s Worker: Applicant currently works for your organisation in a children’s worker role. VCA Renewal: Subsequent vetting request for an existing children’s worker, required once every three years. Application of the Criminal Records (Clean Slate) Act 2004: The NZ Police Vetting Service must comply with the Criminal Records (Clean Slate) Act 2004. Your answers to the above questions will assist us in determining what section of the Act applies to this vetting request. Section 16 (Clean Slate): Conviction history will not be released if applicant is eligible for clean slate. The role does not fit the criteria in section 19(3) of the Criminal Records (Clean Slate) Act, e.g. teacher, doctor/nurse, rest home carer.
Section 19(3) (Exception): All criminal convictions will be released EVEN IF the applicant is eligible for clean slate. The role fits the criteria of one or more of the exceptions in section 19(3) of the Criminal Records (Clean Slate) Act e.g. it is a role predominantly involving the care and protection of, but not predominantly involving the delivery of education to, a child or young person (e.g. caregiver, nanny, foster/homestay parent, applicant for adoption) [section 19(3)(e)].
For information on the clean slate regime, see http://www.justice.govt.nz/services/criminal‐records/about‐the‐criminal‐records‐clean‐
slate‐act‐2004.
Page 1 of 7 NZPVS‐CS ‐ 07/15 Vetting Service Request and Consent Form
Section 1 continued: Approved Agency to complete EVIDENCE OF IDENTITY (ID) ‐ for further information, see http://www.dia.govt.nz/Resource‐material‐Evidence‐of‐Identity‐Standard‐Index I confirm that the identity of the applicant has been checked by [A] or [B] as follows: [A] I have (or my delegate has), OR, A Trusted Referee* has sighted the ID documents below, and verified the photo against the applicant in person (mark box) Primary ID document (e.g. passport, original birth certificate, firearms licence, etc; see link above)
and Another form of ID (e.g. driver licence, 18+ card, Community Services Card, etc; see link above) and One of the above must be photographic – confirm comparison made and, if applicable Evidence of name change where names differ (e.g. marriage/civil union certificate, statutory declaration, etc
* a Trusted
etc) Referee must be over 16, and not be related, or a partner/spouse, or a co-resident of the applicant, and be either a person of standing in the
community (e.g. registered professional, religious or community leader, Police employee) or registered with the Approved Agency. The Trusted Referee must:
[*a trusted referee must be over 16, and not be related, or a partner/spouse, or a co‐resident of 1.
sign
and date the copies of identity documents, and endorse each of them appropriately e.g.
•applicant, and be either a person of standing in the community (e.g. registered professional, religious "I have sighted the original version of this document"
•or community leader) or registered with the Approved Agency. The Trusted Referee must sign a copy I have sighted the original version of this document and I have compared the photographic image with
(name of applicant)
and confirm they apear to be the same person."
2.
of the photo ID and provide his or her name and contact details.]
provide her is his name and contact details
Optional additional check by me (if appropriate) [B] A search of our records to verify uniqueness (especially for professional bodies) I have received an assertion of a RealMe verified identity ‐ limited to agencies who are able to use RealMe to verify identity ‐ for further information, see https://www.realme.govt.nz/ CHECKLIST In making this request, I confirm that: I have complied and will comply with the Approved Agency Agreement (or existing Memorandum of Understanding) between NZ Police and the Approved Agency I represent; I am satisfied as to the correctness of the Applicant’s identity (if applicable I confirm that Trusted Referee contact details have been provided); and I have obtained the Applicant’s authorisation to submit this vetting request, as set out in section 2 of this form. Approved Agency Authorised Representative: Name:
Date: Signed in electronic form: [mark box]
OR
Signature:
Page 2 of 7 NZPVS‐CS ‐ 07/15 Vetting Service Request and Consent Form
Name of Approved Agency submitting vetting request: Applicant to complete and return to Approved Agency Section 2: (the Approved Agency will submit the vetting request to NZ Police and receive the vetting result) PERSONAL INFORMATION Details (note: the name you are most commonly known by is your primary name) *Family name: (Primary) First name(s):
*Gender: (M) (F) (Other) *Place of birth: (town/city/state) NZ Driver Licence number: (*where held ‐ for ID verification by NZ Police) (Primary)
*Date of birth:
(dd/mm/yyyy) *Place of birth: (country) If applicable, please include other names and mark them A, M, or P as appropriate:
(A) alias or alternate name(s) (M) married name if not primary name (P) previous/maiden/name changed by deed poll or statutory declaration (A) (M) (P) Family name: Family name: Family name: (A) (M) (P) (A) (M) (P) (A) (M) (P) First name(s):
(A) (M) (P) First name(s):
(A) (M) (P) First name(s):
(A) (M) (P) First name(s):
(A) (M) (P) *Number/Street: Suburb: *City/Town/ Rural District: Permanent New Zealand Residential Address Family name: Post Code: *Period of Residence: *Denotes a mandatory field Page 3 of 7 Vetting Service NZPVS‐CS ‐ 07/15 Request and Consent Form
Section 2: continued Applicant to complete and return to Approved Agency (the Approved Agency will submit the vetting request to NZ Police and receive the vetting result) CONSENT TO DISCLOSURE (for a New Zealand Police Vet) ‐ for further information, see http://www.police.govt.nz/advice/businesses‐and‐organisations/vetting I acknowledge and understand as follows: 1. The information about me that NZ Police may consider relevant to my application and release in vetting comprises any conviction history and, for certain agencies, infringement/demerit reports; and it may include any other information such as active charges and warrants to arrest, any information received or obtained by NZ Police, and any interaction I have had with NZ Police in any context (including family violence), even where I have not been charged, or charges are withdrawn, or I have been acquitted (not guilty) of a charge, or I have been discharged without conviction. 2. Any conviction history will be released in accordance with the Criminal Records (Clean Slate) Act 2004; this means that, if I am ‘eligible’ for clean slate (e.g. no convictions for 7 years, never been to prison, no convictions for specified sexual offending, etc – see section 7 of the Act): a. my criminal record of convictions will not be disclosed; but b. if the role for which I have applied is an exception to the clean slate scheme (e.g. predominantly involving care and protection of a child or young person), my criminal record of convictions will be disclosed. 3. Where relevant information is subject to statutory or Court‐ordered name suppression or prohibitions on disclosure, or other constraints on disclosure such as expectations of confidentiality or the protection of active criminal investigations or the safety of individuals, NZ Police may issue an alternative vetting result stating the existence of relevant non‐disclosable information, without details. 4. Where new information is obtained by NZ Police after the completion of my Police vet, NZ Police may disclose this information to the Approved Agency, and where appropriate to the Vulnerable Children Act Exemptions Administrator, if the information is considered relevant to the purpose of the Police vet. 5. The personal information I provide in this form is being collected for vetting purposes, and may also be used for the purpose of updating NZ Police records. 6. I may withdraw this consent, prior to Police’s disclosure of the vetting result, by notifying the Approved Agency who will immediately notify NZ Police to cease the vetting process (any fee remains payable by the Approved Agency). 7. I am entitled to access the vetting result released to the Approved Agency and seek correction of Police information about me in accordance with the Privacy Act 1993 by making a request to the 'Approved Agency' in the first instance. 8.
No later than twelve months after the release of the vetting result, the Approved Agency will securely dispose of this consent form and copies of identification documents, as well as the vetting result released by NZ Police, unless a longer retention period is required by legislation applying to the Approved Agency. 9. The information I have provided in this form relates to me and is correct. Applicant’s Authorisation: I have read and understood the information above
I authorise NZ Police to disclose any personal information it considers relevant to my application (as described above) to the Approved Agency making this request for the purpose of assessing my suitability.
Signed in electronic form: [mark box] OR
Signature:
Date: Page 4 of 7 NZPVS‐CS ‐ 07/15 Vetting Service Request and Consent Form
Section 3: Applicant to complete for Australian check (if required) ADDITIONAL PERSONAL INFORMATION (for Australian National Police History Check) Last Permanent Australian Residential Address
Number/Street: Suburb: City/Town/ Rural District: Period of Residence Post Code: State or Territory: If actual dates of residence are unavailable, year of residence will suffice Australian Driver's Licence No: (if applicable) Australian Firearms Licence No: (if applicable) CONSENT TO DISCLOSURE Issued by:
Issued by:
General Information for an Australian National Police History Check GENERAL INFORMATION
CrimTrac is collecting your personal information in this form in
order to conduct a National Police History Check (NPHC) on you.
Approved Agencies in New Zealand, named in section one, use the
personal information collected on this form and the resulting NPHC
as part of the assessment process to determine suitability for the
position/entitlement/benefit which you are applying for.
Unless statutory obligations require otherwise, the information
provided on this form will not be used without your prior consent
for any purpose other than in relation to the assessment of your
suitability or to maintain the records of CrimTrac, Australian Police
Agencies1, or NZ Police.
You will be required to complete another consent form for any
future NPHC checks.
NATIONAL POLICE HISTORY CHECK (NPHC)
A NPHC is an integral part of the assessment of your suitability.
Information on this form will be used by CrimTrac, and Australian
Police Agencies for checking action; it will also be used to update
records held about you by CrimTrac,
Australian Police Agencies and NZ Police.
LIMITATIONS ON ACCURACY AND USE OF POLICE
HISTORY INFORMATION
While every care has been taken by CrimTrac to conduct a search
of information held by Australian Police Agencies that relate to
the applicant, the accuracy and quality of this NPHC depends on
accurate identification of the Applicant (including aliases)
according to the information provided in the Request and
Consent Form and the comprehensiveness of police records. If the
applicant does not complete the information requirements in this
form the success and validity of the NPHC will be compromised.
If for any reason you do not agree with the results of your NPHC,
please notify the Approved Agency that you submitted the check
through in the first instance, so that the NPHC dispute process can
be initiated.
The release of information by Australian Police Agencies is subject
to relevant Spent Convictions, non-disclosure legislation or
information release policies.
Information released may include outstanding charges, warrant
information and criminal convictions/findings/pleas of guilt
recorded against you that may be disclosed according to the laws
of the relevant jurisdiction and, in the absence of any laws
governing the release of that information, according to the
relevant jurisdiction information release policy.
1
Australian Federal Police, ACT Policing, The New South Wales Police Force, Queensland Police Service, South Australia Police, Victoria Police, Western Australia Police,
Northern Territory Police Force, Tasmania Police Service
Page 5 of 7 Vetting Service NZPVS‐CS ‐ 07/15 Request and Consent Form
General Information for an Australian National Police History Check, continued SPENT CONVICTIONS SCHEMES
The aim of Spent Convictions legislation2 is to prevent
discrimination on the basis of certain previous convictions. Spent
Convictions legislation limits the use and disclosure of older, less
serious convictions and findings of guilt. Each Australian Police
Agency will apply the relevant Spent Convictions
legislation/information release policy prior to disclosure.
The following links may be helpful in sourcing information on
Spent Convictions in the Australian States & Territories but may not
be relied upon.
If further information or clarification is required please contact the
individual Australian Police Agencies directly for further
information about their release policies and any legislation that
affects them.
PROVISION OF INCOMPLETE, FALSE OR MISLEADING
INFORMATION
An Approved Agency or Applicant must take reasonable steps to
ensure that the personal information collected, or disclosed is
accurate, complete and up to date.
You are asked to certify that the personal information you have
provided on this form is correct. If it is subsequently discovered,
for example as a result of a check of police records, that you have
provided incomplete, false or misleading information, you may be
assessed as unsuitable.
It is a serious offence to provide false or misleading information in
Australia.
Commonwealth
www.comlaw.gov.au
New South Wales
www.legislation.nsw.gov.au
Queensland
www.legislation.qld.gov.au
South Australia
www.legislation.sa.gov.au
Victoria Police
www.police.vic.gov.au
Western Australia
www.slp.wa.gov.au
Northern Territory
www.nt.gov.au/dcm/legislation/current.html
Australian Capital Territory
www.legislation.act.gov.au
Tasmania
www.thelaw.tas.gov.au
2
Applicable Spent Conviction legislation, as amended from time to time
Page 6 of 7 Vetting Service NZPVS‐CS ‐ 07/15 Request and Consent Form
Section 3: continued Applicant to complete for Australian check (if required) CONSENT TO DISCLOSURE (for Australian National Police History Check) I acknowledge, understand and consent as follows:
1.
I have read the General Information in section 3 of this form and understand that information will be disclosed in accordance
with applicable legislation and information release policies (including spent convictions legislation, however described) in the
Commonwealth, States and Territories;
2.
I understand that the position/entitlement for which I am being considered may be in a category for which exclusions from
Spent Convictions legislation may apply;
3.
I have fully completed this form, and the personal information I have provided in it relates to me, contains my full name and all
names previously used by me, and is correct;
4.
I acknowledge that the provision of false or misleading information is a serious offence;
5.
I acknowledge that the Approved Agency named in Section 1 of this form is collecting information in this Form to provide to
NZ Police to provide to CrimTrac (an Agency of the Commonwealth of Australia) and the Australian Police Agencies;
6.
I consent to:
a.
CrimTrac using and disclosing personal information about me in this form to the Australian Police Agencies;
b.
the Australian Police Agencies disclosing to CrimTrac, from their records, Police History information that can be disclosed
in accordance with the laws of the Commonwealth, States and Territories and in accordance with the relevant
jurisdiction’s information release policies;
c.
CrimTrac disclosing the information disclosed by the Australian Police Agencies to NZ Police, and
d.
NZ Police disclosing any criminal history information about me to the Approved Agency named in Section 1 of this form to
assess my suitability in relation to my application;
7.
I acknowledge that any information provided by me in this form relates specifically to the purpose identified in Section 1 of this
form;
8.
I acknowledge that any information provided by the Australian Police Agencies or CrimTrac relates specifically to the purpose
identified in Section 1 above;
9.
I acknowledge that personal information that I provide in this form may be disclosed to the Approved Agency named in
Section 1 of this form (including contractors or related bodies corporate) located in New Zealand or overseas; and
10. I acknowledge that it is usual practice for an Applicant's personal information in this form to be disclosed to NZ Police and
Australian Police Agencies for them to use for their respective law enforcement purposes including the investigation of any
outstanding criminal offences.
Note: The information provided in this form will be used only for the purpose stated above unless statutory obligations require
otherwise.
Applicant’s Authorisation: I have read and understood the information above and consent accordingly Signed in electronic form: [mark box]
OR
Signature:
Page 7 of 7