Application Form

DHS Screening

Application Form AP2110804 (Version: 1)

Referring Organisation DHS - Applicant Initiated
Applicant Name Phan Thanh Tran Nguyen

Screenings

Screening Number Screening Type

SC2227996 Aged Care Sector Employment

SC2227997 General Employment Probity

SC2227998 Vulnerable Person Related Employment

SC2227999 Working With Children Check

SC2228000 NDIS worker check

You have selected PRINT AND SEEK VERIFICATION

Please print your application form and take this form together with ORIGINAL copies of your identity
documents to an independent Verifying Officer. Information on who can verify your documents is
available on: Verifying officers - [Link]
The Verifying Officer will then confirm that they have sighted your documents and will verify your form.
Please note: At least one category A document or One Category B document (which contains a
photograph) must be used. Information on identity documents is available on: Print and seek verification
- [Link]

Your Personal Details

Title: Miss

Current Last name: Nguyen Current First name: Phan Thanh Tran

Current Middle name:

Reference Number:

Gender: Female

Date of Birth: 26/11/2004 Town/city of birth: Long Xuyen

State/Territory of birth: An Giang Place of Birth: Vietnam

Do you identify as Aboriginal or Torres Strait Islander?

Your Previous Names

No Previous Names recorded

Page 1 of 11
 AP2110804 (Version: 1)

Your current contact details

Unit No: Street: 33 EDWARD STREET

Suburb/town: OTTOWAY State: SA Postcode: 5013

Period of residence From: 29/10/2019

Telephone: (H) (W) 0451802991 (M)

Email address: nguyenphanthanhtran@[Link]

Current postal address: Postal Address same as Residential Address:

Unit No: Street: 33 EDWARD STREET

Suburb/town: OTTOWAY State: SA Postcode: 5013

Your previous residential addresses

No Previous Addresses recorded

Declaration and Informed Consent

Declaration

1. Have you ever been dismissed or resigned from any employment or a volunteer role in
Yes No
response to or following allegations of improper conduct relating to children?
2. Have you been (or are you currently) the subject of any professional disciplinary
proceedings, or any action that might lead to such proceedings in any jurisdiction? (not Yes No
including criminal court proceedings).
3. Have you ever been (or are you currently) subject to any restrictions regarding your
contact with children (including removal of a child) in any employment, volunteer, or Yes No
personal capacity?
4. Have you ever been found guilty of an offence committed in a country other than
Yes No
Australia, including an offence for which no conviction was recorded?
5. Have you been named as the defendant in an Interim or Confirmed Intervention Order,
Restraining Order, Apprehended Violence Order, Domestic Violence Restraining Yes No
Order, Paedophile Restraining Order or equivalent, in any jurisdiction?
6. Are you currently or have you ever been a registrable sex offender? (e.g. Australian
Yes No
National Child Sex Offender Register)
7. Have you ever been denied an employment screening clearance or working with
Yes No
children clearance from another Australian jurisdiction?
8. Have you ever been convicted of an offence committed in a country other than
Yes No
Australia?
9. Have you ever been convicted of murder, sexual assault or any form of assault for
which a sentence of imprisonment (regardless of suspension) was imposed in an Yes No
Australian court?
10. Have you ever been convicted of murder, sexual assault or any form of assault for
which a sentence of imprisonment (regardless of suspension) was imposed in a Yes No
country other than Australia?
11. Have you ever been denied an employment screening clearance from another
Yes No
jurisdiction?
12. Are you currently suspended, or have you ever been refused, barred, excluded,
prohibited, or disqualified following an application for an NDIS Worker Screening
Check, Working With Children Check, Working With Vulnerable People Registration Yes No
and/or working with people with a disability check (or equivalent) in any state or
territory in Australia?

Page 2 of 11
 AP2110804 (Version: 1)

13. Have you ever been convicted or found guilty of any of the following, or equivalent,
offences in a country other than Australia? murder, attempted murder, or
manslaughter, serious or aggravated assault, rape, bestiality, sexual assault, or
incest, aggravated robbery, child pornography offences, abduction, kidnapping,
Yes No
human trafficking, or slavery, drug trafficking and drug dealing, neglect or
ill-treatment of a child or vulnerable person, fraud, deception, or forgery involving a
child or vulnerable person, treason/treachery, terrorism, genocide, mutiny, or
espionage, animal cruelty causing an animal serious injury, harm, or death
14. Have you ever been subject of an investigation by any government agency anywhere
in Australia that involved allegations of abuse or neglect of a child in your care that
Yes No
resulted in restrictions regarding your contact with that child or other children
(including the removal of a child/children)?
15. Have you ever had any workplace misconduct findings against you, or are you subject
to a current investigation, in relation to: violent behaviour or assault, indecent or
Yes No
sexual behaviour or misconduct, fraud, deception or theft, failing to provide care for a
vulnerable person such as a child, elderly person or person with disability.
16. Have you ever been dismissed or resigned from any employment or a volunteer role in
response to or following allegations of improper conduct relating to a child, elderly Yes No
person or person with disability?
17. Have you ever submitted an application for employment or a volunteer role involving
contact with children, people with a disability, or elderly persons which was declined Yes No
for disciplinary reasons or allegations of improper conduct?
18. Have you been named as the defendant in an Interim or Confirmed Intervention Order,
a Domestic Violence Order, a Restraining Order, an Apprehended Violence Order,
Yes No
Domestic Violence Restraining Order, a Paedophile Restraint Order, a Child
Protection Order, or equivalent, in any jurisdiction?

Consent to Obtain Personal Information

I, Phan Thanh Tran Nguyen hereby;

1. Acknowledge that I understand the information on this form.

2. Declare that the personal information I have provided on this form relates to me.
3. Declare I have fully and accurately completed this form, my personal information is complete and
correct, and contains my full name and all names I have been known by or used, including previous
names, aliases, and informal names.
4. Acknowledge that withholding and/or providing misleading or false information on this form and in any
supplied identity documents I may have provided is a Commonwealth offence and may lead to
prosecution under the Criminal Code Act 1995 (Cth)
5. Acknowledge that if I have provided false, misleading, incorrect, or incomplete information my
application will be cancelled without refund and any clearance I hold will be revoked.
6. Acknowledge that any information sent by mail or electronically, in relation to this form, including any
supplied identity documents, is sent at my risk and I am aware of the consequences of sending
information in these ways.
7. Consent to the Department of Human Services’ (DHS) Screening Unit (ABN 11 525 031 744) accessing
personal information I have provided in previous screening applications, which was collected by the
DHS Screening Unit with my consent, for the purpose of the DHS Screening Unit using and disclosing
this information to undertake functions I have consented to it performing as part of this application.
8. Understand that the employers and/or organisations that engage me in work related to the purposes of
the screening check/s contained in this application shall make the final decision as to my engagement in
the position.
9. Understand that decisions made regarding complex risk assessments may be determined by a panel of
DHS senior officers.
10. Acknowledge that the DHS Screening Unit is collecting information in this form to provide to the
Australian Criminal Intelligence Commission (ACIC) and police agencies for a nationally coordinated
criminal history check to be conducted for the purpose related to the screening check/s I have applied
for in this application form.

Page 3 of 11
 AP2110804 (Version: 1)

11. Acknowledge that I am aware that I am providing consent for a nationally coordinated criminal history
check to be conducted using all personal information provided in this form and provided in any supplied
identity documents.
12. Give consent to: the ACIC and police agencies using and disclosing my personal information that have
provided in this form and personal information contained in any supplied identity documents to conduct
a nationally coordinated criminal history check. The ACIC disclosing the police information sourced from
the police agencies to the DHS Screening Unit. The storage of my personal and police information
off-shore (Japan) in Salesforce cloud-based storage software.
13. Understand and acknowledge that the ACIC and Australian police agencies will disclose police
information about me to the DHS Screening Unit which may include, but is not limited to, convictions,
findings of guilt, pending charges, spent convictions, non-conviction outcomes, and circumstantial
information relating to offences committed or allegedly committed by me, regardless of when and where
the offence or alleged offence occurred, and what the outcome may have been.
14. Understand and acknowledge that it is usual practice for my personal information and police information
to be used by police agencies and the ACIC for law enforcement, including purposes set out in the
Australian Crime Commission Act 2002 (Cth).
15. Understand and acknowledge that the DHS Screening Unit will use or disclose personal information,
police information, or other sensitive information about me in accordance with the Privacy Act 1988
(Cth), Australian Privacy Principles (APPS), Information Privacy Principles (IPPS) Instruction and
when: it is legally required or authorised, such as by an Australian law, or court or tribunal order, the
DHS Screening Unit believes on reasonable grounds that the use and disclosure of the information is
necessary to prevent or lessen a serious threat to my life, the health or safety of some other person, or
to public health or safety, the DHS Screening Unit believes the use is reasonably necessary for the
enforcement of the criminal law or of a law imposing a pecuniary penalty or for the protection of the
public revenue or for the protection of the interests of the government, statutory authority or statutory
office-holder as an employer, the DHS Screening Unit has reason to suspect that unlawful activity has
been, is being or may be engaged in, and discloses the information in reporting our concerns to relevant
persons or authorities, or, the Screening Unit reasonably believe that the use relates to information
about an individual that suggests that the individual has engaged or may engage in illegal conduct or
serious misconduct in relation to a person; and the Screening Unit reasonably believes that the use is
appropriate in the circumstances; and the use complies with any guidelines issued by the Minister of the
Department of Human Services for the purposes of this clause.
16. Consent to the DHS Screening Unit obtaining a recent photograph from me when required and in form
determined by the DHS Screening Unit.
17. Understand and acknowledge that, for the purpose of a working with children check, the DHS Screening
Unit, being the central assessment unit established under the Child Safety (Prohibited Person) Act 2016
(SA), is authorised to receive and make use of information related to me that is relevant to performing its
functions under the Child Safety (Prohibited Person) Act 2016 (SA) from any person or body in South
Australia or any other jurisdiction including, but not limited to, information from: police services, courts,
prosecuting authorities, government agencies, statutory authorities, my employer/s.
18. Understand and acknowledge that, for the purpose of a working with children check, the DHS Screening
Unit, is authorised to disclose information related to me (not being information classified by the
Commissioner of Police as criminal intelligence) in the possession of the DHS Screening Unit to a
prescribed person or body in another State or Territory for purposes related to the screening of me to
work with children (being a person or body whose official function consists of or includes the screening
of persons who work with children (however described); or any other person or body prescribed by the
Child Safety (Prohibited Persons) Regulations 2019 (SA) for the purposes of this clause.
19. Understand and acknowledge that, for the purpose of a working with children check, the DHS Screening
Unit is authorised to disclose information related to me, in the possession of the DHS Screening Unit,
when compelled to do so in accordance with a law of the State of South Australia or the Commonwealth.
20. Consent to the DHS Screening Unit, providing my relevant criminal history information, to the public
sector agency who has requested a working with children check be conducted in relation to me, where
the DHS Screening Unit has an existing agreement in place with the agency to do so to enable the
agency to use my relevant criminal history information for purposes authorised under the legislative and
regulatory instruments governing that agency’s functions.
21. Understand and acknowledge that, for the purpose of a working with children check, in accordance with
the Child Safety (Prohibited Person) Act 2016 (SA), the DHS Screening Unit will notify all my known
employers and/or organisations I volunteer with, who have registered to notified, if I become a prohibited
person through the operation of section 15 of the Child Safety (Prohibited Person) Act 2016 (SA).

Page 4 of 11
 AP2110804 (Version: 1)

22. Understand and acknowledge the DHS Screening Unit, will conduct an additional working with children
check on me, upon receipt of new or additional information to determine if I am prohibited or not
prohibited from engaging in child related work.
23. Understand and acknowledge that, for the purpose of a working with children, where the DHS Screening
Unit, determines I am not prohibited from engaging in child related work that the organisation and,
where applicable, the relevant government supervisory agency, contemplating engaging me in child
related work, shall make the final determination as to my suitability to be engaged.
24. Consent to a nationally coordinated criminal history check being made in relation to me for the purpose
of an additional or further working with children check being conducted under section 30 and section 33
of the Child Safety (Prohibited Persons) Act (SA).
25. Consent to a nationally coordinated criminal history check being made in relation to me for the purpose
of the DHS Screening Unit reconsidering a decision to prohibit me from working with children check
pursuant to an order made by the South Australian Civil and Administrative Tribunal.
26. Understand and acknowledge the DHS Screening Unit may disclose information about me obtained in
the operation or administration of the Child Safety (Prohibited Persons) Act (SA) for the purpose of
providing relevant information for entry in a national register or database relating to the screening of
persons who work with children.
27. Consent to the DHS Screening Unit, being the central assessment unit established under the Child
Safety (Prohibited Person) Act 2016 (SA), making inquiries about me for the following NDIS purposes in
relation to my NDIS worker check: verification of my identity, consideration and determination of my
application for an NDIS worker check, assessing and determining under the Disability Inclusion Act
(2018) whether I pose a risk of harm to people with disability, assessing and determining whether a risk
assessment related to me is required under a Disability Inclusion Act (2018), an administrative review
(including internal review) of a decision made in relation to me under the Disability Inclusion Act (2018).
28. Consent to the DHS Screening Unit, obtaining relevant information about me from any authorised
person for an NDIS purpose including, but not limited to, relevant information from: a person or body
exercising functions in the operation or administration of a relevant law, the NDIS Quality and
Safeguards Commission, a law enforcement agency of South Australia or any other jurisdiction
(including a jurisdiction outside Australia), any other person declared by the Disability Inclusion (NDIS
Worker Check) Regulations 2020.
29. Consent to the disclosure of relevant information about me by the DHS Screening Unit in accordance
with the Disability Inclusion Act 2018 (SA) to an authorised person for any purpose that is for, or in
connection with, the operation or administration of, or compliance with, a relevant law, and including, but
not limited to, relevant information from: a person or body exercising functions in the operation or
administration of a relevant law, the NDIS Quality and Safeguards Commission, a law enforcement
agency of South Australia or any other jurisdiction (including a jurisdiction outside Australia), any other
person declared by the Disability Inclusion (NDIS Worker Check) Regulations 2020.
30. Consent to a nationally coordinated criminal history check being made by the DHS Screening Unit in
relation to me at any time while I hold a NDIS worker check clearance.
31. Consent to a nationally coordinated criminal history check being made in relation to me for the purpose
of the DHS Screening Unit reconsidering a decision to exclude me from working with people with
disability, or a decision to suspend me from working with people with disability, or a decision to cancel
my NDIS worker check clearance, pursuant to an order made by the South Australian Civil and
Administrative Tribunal.
32. Consent to a nationally coordinated criminal history check being made in relation to me for the purpose
of the DHS Screening Unit conducting an internal review of a decision to exclude me from working with
people with disability, or a decision to suspend me from working with people with disability, or a decision
to cancel my NDIS worker check clearance.
33. Consent to the DHS Screening Unit, a person or body whose official function consists of or includes the
screening of persons who work with people with disability (however described), and law enforcement
agency or court in any jurisdiction, conducting ongoing monitoring of any relevant information related to
me (including but not limited to pending criminal charges) for the purpose of determining whether a risk
assessment is required in relation to me and/or for the purpose of determining whether I pose a relevant
risk of harm in relation to my NDIS worker check application (from the time I submit my application), and
any NDIS worker check clearance, or other authority I hold under a relevant law.
34. Understand and acknowledge that I cannot withdraw my consent to be screened but I may withdraw an
application for an NDIS worker check at any time; however the withdrawal only has effect if the DHS
Screening Unit consents to the withdrawal.

Page 5 of 11
 AP2110804 (Version: 1)

35. Understand and acknowledge that I must notify the DHS Screening Unit if I change in my name,
residential address, or contact details, or use another name or names within 3 months of the change
occurring.
36. Understand that if I am issued an NDIS worker check clearance I may only re-apply for an NDIS Worker
Screening Check three months prior to the expiry of my existing clearance, unless otherwise advised by
the DHS Screening Unit, and I may continue to work while my re-application is considered only if I lodge
a valid application that has been verified by my NDIS employer before the expiry of my existing
clearance.
37. Understand and acknowledge that if the DHS Screening Unit issues an NDIS worker check exclusion in
relation to me because I have been found guilty of a disqualification offence under the Disability
Inclusion Act 2018 (SA) I am excluded indefinitely from working with people with disability.
38. Understand and acknowledge that if the DHS Screening Unit issues an NDIS worker check exclusion in
relation to me, but I am not disqualified indefinitely, I may not re-apply for an NDIS worker check for a
period of five years from the date of the exclusion, unless the DHS Screening Unit is satisfied there is a
relevant change in my circumstances that would allow for an early application.
39. Understand and acknowledge the DHS Screening Unit is authorised to receive and make use of
information related to me that is relevant to performing its functions under the Disability Inclusion Act
2018 (SA) from any person or body in the State of South Australia or any other jurisdiction including, but
not limited to, information from: police agencies, a person or body whose official function consists of or
includes the screening of persons who work with people with disability (however described), courts,
prosecuting authorities, the NDIS Quality and Safeguards Commission, government agencies, statutory
authorities.
40. Understand and acknowledge the DHS Screening Unit is authorised to disclose any information related
to me (not being information classified by the Commissioner of Police as criminal intelligence) in the
possession of the DHS Screening Unit to a prescribed person or body in another State or Territory for
purposes related to the screening of me to work with people with disability including disclosing
information to: a person or body whose official function consists of or includes the screening of persons
who work with people with disability (however described), the NDIS Quality and Safeguards
Commission, the Australian Criminal Intelligence Commission, the National Disability Insurance Agency,
the Department of Social Services of the Commonwealth.
41. Understand and acknowledge the DHS Screening Unit may disclose to a law enforcement agency of the
State or any other jurisdiction (including a jurisdiction outside Australia) any information obtained as a
result of the exercise of a function under Part 5A of the Disability Inclusion Act 2018 (SA) that indicates
that a relevant offence may have been committed by me or that constitutes evidence of a relevant
offence.
42. Understand and acknowledge the DHS Screening Unit and any other authorised person may disclose to
an appropriate person or body any information obtained about me in the operation or administration of
Part 5A of the Disability Inclusion Act 2018 (SA) or other relevant law if there are reasonable grounds to
suspect that there is a risk of significant harm to a person with disability, or to a child or other vulnerable
person, or to a class of such persons, and the disclosure is reasonably necessary to prevent that harm.
43. Consent to relevant information about me, including but not limited to any misconduct or disciplinary
action (such as compliance or enforcement action) being sought from, provided by, shared with and
retained by the NDIS Quality and Safeguards Commission or a person or body whose official function
consists of or includes the screening of persons who work with people with disability (however
described).
44. Understand and acknowledge the DHS Screening Unit may provide the following information about me
to an NDIS employer or participant who engages or proposes to engage me to do NDIS work:
information relevant to verification of my identity, information about the outcome of any application I
have submitted for a NDIS worker check clearance, information about any risk assessment made in
relation to me.
45. Understand and acknowledge my registered NDIS employers (NDIS provider or self-managed
participant) are responsible, in accordance with the NDIS (Practice Standards – Worker Screening)
Rules 2018, for assessing whether or not I need an NDIS worker check or other acceptable check and
that if I do not have more than incidental contact with people with disability as a normal part of my jobs
(for example, administrative support staff for a registered NDIS provider), it is not mandatory to have a
check, but my employer can still require me to get one.

Page 6 of 11
 AP2110804 (Version: 1)

46. Understand and acknowledge, the DHS Screening Unit may disclose information obtained in the
operation or administration of Part 5A of the Disability Inclusion Act 2018 (SA) to an authorised person
for the purpose of providing relevant information for use for the purposes of research into the operation
of a relevant law, or auditing of compliance with such laws.
47. Understand and acknowledge, the DHS Screening Unit, a person or body whose official function
consists of or includes the screening of persons who work with people with disability (however
described), a law enforcement agency in any jurisdiction may disclose information obtained in the
operation or administration of Part 5A of the Disability Inclusion Act 2018 (SA) or other corresponding or
relevant law to the NDIS Quality and Safeguards Commission, for the purpose of providing relevant
information for entry in the NDIS Worker Screening Database established under the National Disability
Insurance Scheme Act 2013 (Cth).
48. Understand and acknowledge that the NDIS Quality and Safeguards Commission will use the NDIS
Worker Screening Database to undertake its statutory functions under the National Disability Insurance
Scheme Act 2013 (Cth).
49. Understand and acknowledge relevant information entered on the NDIS Worker Screening Database
will include: limited personal information I have provided, including in this application form (but not
criminal or other information used by the Screening Unit in assessing my application), limited personal
information about me provided by my NDIS employer/s (for example, work site address), details about
decisions undertaken by the DHS Screening Unit, or any other person or body whose official function
consists of or includes the screening of persons who work with people with disability (however
described).
50. Understand and acknowledge that once a record has been created for me on the NDIS Worker
Screening Database: that record will continue to exist on the NDIS Worker Screening Database, and my
information will continue to be included in that record, even if I no longer work in the NDIS sector, that
NDIS employers will be able to access information about me on the NDIS Worker Screening Database
(unless they are no longer linked to me).
51. Understand and acknowledge that NDIS employers will be able to see the following about me on the
NDIS Worker Screening Database: my worker screening ID, my first and last name, my date of birth,
status (clearance, exclusion, interim bar, suspension), the expiry date of my NDIS worker check
clearance, my eligibility to work.
52. Understand that NDIS employers who are linked to me in the NDIS Worker Screening Database will be
notified of any changes to my clearance status, including if I am no longer cleared to work.
53. Consent to the DHS Screening Unit, obtaining a nationally coordinated criminal history check results
report in relation to me for the purpose of conducting an assessment of my criminal history on behalf of
the aged care provider/s requiring a nationally coordinated criminal history check be conducted to meet
the requirements of Part 6 of the Accountability Principles 2014 made under the Aged Care Act 1997
(Cth)
54. Understand and acknowledge that, for the purpose of aged care screening, my criminal history will be
assessed by the DHS Screening Unit in accordance with the Australian Department of Health’s Police
Certificate Guidelines to determine whether I pose a risk to aged care recipients.
55. Understand and acknowledge that I am precluded from working in aged care if a nationally coordinated
criminal history check results report records that I have been: convicted of murder or sexual assault; or
convicted of, and sentenced to imprisonment for, any other form of assault.
56. Consent to the DHS Screening Unit and police agencies conducting ongoing monitoring of police
records to assess if I pose a risk to aged care recipients and, where I hold an aged care screening
clearance, determine whether that clearance should be revoked.
57. Consent to the DHS Screening Unit, for the purpose of an aged care screening, providing the nationally
coordinated criminal history check results report, if deemed necessary, to the aged care provider
requiring my screening or another entity seeking the report on behalf of that organisation where
permitted by ACIC.
58. Consent to the DHS Screening Unit, for the purpose of a vulnerable person related employment
screening, using the nationally coordinated criminal history check results obtained in relation to me and
any of the information provided by me on this form to determine whether I pose a risk to vulnerable
people.
59. Consent to the DHS Screening Unit care and police agencies conducting ongoing monitoring of police
records to assess if I pose a risk to vulnerable people and, where I hold a vulnerable person related
employment screening clearance, determine whether that clearance should be revoked.

Page 7 of 11
 AP2110804 (Version: 1)

60. Consent to the DHS Screening Unit, for the purpose of a general probity employment screening, using
the nationally coordinated criminal history check results obtained in relation to me and any of the
information provided by me on this form to conduct a risk assessment in relation to the specific
employment role I have recorded in my application form.

Do you agree and consent to the above? Yes No

Verification of Identity

To process your application, the Screening Unit needs to be certain of your identity, and must make
sure you have undergone a 100-point identification check, which has been verified by an appropriate
person.
The details of the verifier MUST be provided below.
Further details on who can verify and how to complete this section are on the website: Print and seek
verification - [Link].

Special Provisions

Special provisions apply to the following categories of applicants, when they are unable to meet the regular
identity verification requirements:

For ABORIGINAL APPLICANTS who reside in remote or isolated locations, apart from the standard
items listed in the 100 point identification check section, there is an added option of TWO letters of
verification provided by community leaders (individuals recognised as leaders of the community to
which the applicant belongs). Each verification scores 50 points.
For IMMIGRANT OR FOREIGN VISITORS (arrival within the past six weeks): proof of arrival date and
current passport will be accepted.
For applicants UNDER 18: One Category A Document or Statement from an educational institution,
signed by the Principal or Deputy Principal, confirming that the child attends the institution (Note:
statement MUST be on the institution’s letterhead).

Verifying Officer Declaration and Details

I declare that:

I have sighted and confirmed the applicant’s original or certified true copy personal identity documents
and that verification has been achieved using the 100-point check.
I am satisfied as to the correctness of the applicant’s identity
I confirm that I meet the requirements for a verifying officer as set out on the website: Verifying officers
- [Link].

Applicant Full Name: Phan Thanh Tran Nguyen

Name of Verifying Officer:

Organisation:

Position:

Telephone: (W) (M)

Email address:

Signature:

Page 8 of 11
 AP2110804 (Version: 1)

100 Point Identification Check

You must provide proof of your identity before your application can be processed. You must show a verifying
officer original identity documents that add up to at least 100 points. Note: a proof of name change certificate
does not count towards the points total. You MUST use ONE Category A document or ONE Category B
document (which contains a photograph). Aboriginal applicants from remote communities or recent migrants
to Australia or applicants under 18 may use identity documents detailed on the previous page.
Category Type of Document Value Points
Category A
Birth Certificate (COMPLETE – NOT EXTRACT)
70 points
Certificate of Australian Citizenship
Only one document from this Australian Passport (CURRENT OR EXPIRED
category will be accepted. WITHIN THE PREVIOUS TWO YEARS, BUT NOT
CANCELLED) 70
Foreign Passport (CURRENT OR EXPIRED WITHIN
THE PREVIOUS TWO YEARS, BUT NOT CANCELLED)
Other international document of identity having
same characteristics as a passport e.g.
diplomatic/refugee document (with identifying
photograph or signature)
Category B Document Australian Motor Vehicle Driver's Licence /
Learner's Permit
Your initial Category B Public Employee Photo ID Card (GOVERNMENT
document is worth 40 points. ISSUED)

Subsequent documents are Department of Veterans’ Affairs (DVA) Card

worth 25 points.
Centrelink Pensioner Concession Card OR 40
Health Care Card (ONE ONLY)
Current Student Photo ID Card (university / high or
school / TAFE)
Reference from a Medical Practitioner (must 25
have known the applicant for a period of at least
12 months)
Working with Children Card OR Teachers
Registration Card (ONE ONLY)
Aviation Security OR Maritime Security
Identification Card (ONE ONLY)

Page 9 of 11
 AP2110804 (Version: 1)

Category Type of Document Value Points

Category C Documents
Extract of a Birth Certificate
25 points
Proof of Age Card (GOVERNMENT ISSUED)
If you wish to use more than Medicare Card OR Private Health Card (ONE
one Category C document, ONLY)
they must be from different
organisations. Seniors Card
Assessment Notice from the Australian Taxation
Office
Superannuation Statement

Electoral roll registration notice

Professional Accreditation OR Trade
Association Card
Foreign / International Driver's Licence

Council rates notice

Property Insurance Confirmation

Property Lease / Rental Agreement 25

Motor Vehicle Registration OR Insurance
Certificate (ONE ONLY)
1st Utility bill (ELECTRICITY / GAS / TELEPHONE
/WATER)

2nd Utility bill (ELECTRICITY / GAS / TELEPHONE

/WATER)

3rd Utility bill (ELECTRICITY / GAS / TELEPHONE

/WATER)

1st Bank / financial institution statement or

passbook
2nd Bank / financial institution statement or
passbook
3rd Bank / financial institution statement or
passbook
1st Credit card / Debit card

2nd Credit card / Debit card

3rd Credit card / Debit card

Must equal or be more than 100 Points TOTAL

DO NOT attach copies of these documents to the application form.

Page 10 of 11
 AP2110804 (Version: 1)

Employment Information

Employment/Placement/Volunteer Details

If the applicant is a prospective employee/student/volunteer, what is their proposed start date? 25/12/2024

Employer Verification

NDIS Employer ID Employer Name

4-IBRA3ZN Torrens University

Screening Unit Contact Details

Please email your completed application form to DHSScreeningUnit@[Link] or post it to the Screening
Unit at GPO Box 292 ADELAIDE 5001.

Page 11 of 11