QUEENSLAND CORRECTIVE SERVICES
ADMINISTRATIVE FORM - AUTHORITY TO DISCLOSE, RELEASE AND EXCHANGE
INFORMATION (CUSTODIAL)
Availability: Public Implement Date: 3 May 2010
I, . D.O.B: / / of authorise the disclosure, release and exchange of information under section 341 of the Corrective Services Act 2006 (CSA) , between an authorised officer of Queensland Corrective Services and the following
—
State/Territory or government department or agencies;
Commonwealth department or agencies; law enforcement agencies; past or present employer; past or present educational authority; medical authorities; including specialists, past treating doctors, alcohol counsellors, agencies / rehabilitation centres and others; legal representatives; other:
I understand the information provided will be used by the department in relation to the following — a) disclosure of information under the CSA; or b) assessment for parole/intensive correction order/probation/leave of absence; or c) parole/intensive correction order/probation/leave of absence supervision; or d) community service orders (including fine option orders) assessment and supervision; or e) preparation of statutory reports, eg parole, pre-sentence and home assessment f) reports; or contravention proceedings; or g) other: _________________________________________________________
I understand the information provided is for determining compliance with supervision requirements and corroborating / verifying information. This authority is given freely and any person or authority connected with the provision of such information, in good faith, is indemnified from any action whatsoever.
This authority is valid from / / to / /
(period of imprisonment, supervision or time required for reports / assessment)
Offender Signature: Date:
CSO Signature: Date:
CSO Name:
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Information Privacy Notice
Sections 263 and 341 of the Corrective Services Act 2006
The Department of Community Safety is collecting the information on this form for the following purposes:
 to ensure that relevant information is obtained from an offender to provide for their effective management and ensure the safe custody and welfare of the offender; and
 for the Department to discharge its legislative, accountability, administrative, reporting, management, personnel and financial functions.
Collection of this information is authorised/required by the Corrective Services Act 2006 .
The Department of Community Safety may give some or all of this information to the Queensland Police Service or other State, interstate, Commonwealth and international government departments or other entities; to private organisations which provide services to offenders and, in some circumstances, to individuals.
In addition to the above uses and disclosures, your personal information may also be used and disclosed as per the Queensland
Corrective Services Offender Privacy Statement.
The statement has been provided to all offenders and is also available in accommodation units, offender libraries and movement control stations where applicable.
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