Fillable BC Blue card application (University of Southern Queensland)

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BC Blue card application (University of Southern Queensland)

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The BC Blue card application (University of Southern Queensland) form is 5 pages long and contains:

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  • 50 check-boxes
  • 67 other fields

Country of origin: AUSTRALIA
File type: PDF

Australia forms for University of Southern Queensland

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1
DJAG 001.V4 MAR19
-
-
Department of Justice and Attorney-General
Blue Card Services
Important Notice
If you are eligible to apply for a blue card (please see disqualified person
#
and negative notice holder
~
definition on page ), continue to complete
this application. If you are not eligible, do not complete this form. Disqualified persons must complete an Eligibility Declaration and negative notice
holders must complete the Application to Cancel a Negative Notice if two years have passed since the negative notice was issued.
NEW/RENEWAL
Valid for lodgement
until 31 March 2020
BC
Blue card application
Working with Children (Risk Management and Screening) Act 
This form is to be completed by paid employees, volunteers and students
proposing to start or continue in child-related employment.
Part A – Child related activity details
(to be completed by the organisation)
1 Please select the type of child-related employment for
which a blue card is required:
Paid employee (payment details required in Part G)
Volunteer (no payment required)
Student (no payment required)
2 Is this application associated with NDIS?
Yes No
3 Is the applicant an EQ staff member or volunteer
Yes You must complete the QSS form 067.
Do not complete this form.
No
Part B – Organisation details
(to be completed by the organisation)
1 Name of organisation
2 Organisation ID number (if known)
3 Postal address of organisation
Postcode
4 Contact person’s name
5 Contact person’s position
6 Telephone
7 Email
Part C – Category of child related activity
(to be completed by the organisation)
Information about categories of child-related employment
and whether any exemptions apply is available from
www.bluecard.qld.gov.au.
Please select the type of child-related activity to which the
employment relates:
Child accommodation services including home stays
Child care
Sta member of an education and care or QEC
service (e.g. long day care, outside school hours care,
kindergarten, occasional care, limited hours care)
~
Other (e.g. nanny, babysitter)
Churches, clubs and associations
Education programs conducted outside school (suspended
or excluded students or flexible arrangements under the
Education (General Provisions) Act )
Emergency services cadet program
Health, counselling and support services
(including disability services)
Licensed care services
Non-State Schools/independent school (other than
registered teachers and parents)
Paid private teaching, coaching or tutoring
Religious representatives
Residential facilities
School boarding houses
School crossing supervisors
Schools, other than EQ sta or volunteers (e.g. P&C,
cleaner)
Sport and active recreation
~ If you apply under this category, information about your
blue card status may be provided to certain regulatory,
supervisory or governing bodies.
Applicant’s name
working at a Queensland State School?
University of Southern Queensland - Facility of HES
16039
USQ, W Block West Street
Toowoomba
4350
Margaret Duffy
Administrator
0 7
4 6 3 1 2 9 7 4
placements.compliance@usq.edu.au
✔
✔
✔
2
DJAG 001.V4 MAR19
Applicant’s name
1 Title Mr Mrs Miss Ms
Other
2 Full legal name
Family name
First name
Middle name
No middle name (please tick)
3 Do you have a previous name, or have you been known
by any other name?
Yes
(record details below) No
It does not matter how long ago you used the name
or how long the name was used for e.g.
• birth name • name before marriage • married name
• alias • change by certificate • adoption
• changed order of name
Family name
First name
Middle name
If you require more space, please tick this box
and attach a separate list.
4 Gender
5 Date of birth
6 Place of birth
Town/City
State/Territory
Country
7 Current postal address (within Australia)
Postcode
8 Current residential address (if different to above)
Postcode
9 Telephone number
Daytime
Mobile
10 Email
11 Do you identify as? (if applicable)
Aboriginal Torres Strait Islander
Aboriginal and Torres Strait Islander
Prefer not to state
12 Previous blue/exemption card number (if applicable):
/
13 Are you, or have you ever been a: (please tick)
Foster or kinship carer
Health practitioner
Operator/supervisor/carer of a child care
or education service
Teacher
14 Applicant’s declaration
I declare that:
• I have read the information on page 4 and I am not
disqualified from applying for a blue card
#
;
• I have read the information on page 4 and I do not
hold a negative notice
~
;
• I am the applicant named in this form and have not
omitted any names or aliases that I use or have used
in the past;
• the information and identification documents provided
by me for this application are true and correct and
I understand it is an offence to provide a false or
misleading statement or document;
• I consent to information from any police, court,
prosecuting authority or other authorised agency
being obtained and for the police, courts, prosecuting
authority or other authorised agency to disclose any
information for the purposes of assessing my eligibility
to work with children including ongoing checks while
my application/blue card remains current;
• I understand that the information obtained includes
but is not limited to details of convictions^ and
pending or non-conviction charges* or information on
the circumstances relating to offences committed or
allegedly committed by me, regardless of when and
where the offence or alleged offence occurred;
• I am proposing to start or continue in regulated
employment and am not entitled to an exemption; and
• I understand and will comply with my blue card
obligations including that I must notify Blue Card
Services within 14 days if I change my name, contact
details, or my child-related employment ends.
Sign inside the box.
Please do not touch or go outside the lines.
Date of signature
Part D – Applicant’s details (to be completed by the applicant)
D D M M Y Y Y Y
D D M M Y Y Y Y
3
DJAG 001.V4 MAR19
Part E – Proof of identity (to be completed by the organisation)
The organisation must check two current, original identification documents from the applicant which collectively show the applicant’s
full name, date of birth and signature. The applicant’s details on their identification documents must match the details provided in
Part D.
One of the following combinations must be used: EITHER
List 1
+
List 1
(one must show a signature)
OR
+
List 2
(one must show a signature)
List 1
If one of the valid identification combinations above cannot be provided, complete and attach a ‘Request to consider
alternative identification’ form.
If the applicant resides more than 50km from the organisation or has a disability which aects their mobility, complete and
submit a ‘Confirmation of identity’ form.
Please indicate which identification documents have been sighted by placing a
in the box.
LIST 1
SIGNATURE DOCUMENT
Driver licence/learner permit/proof of age/photo
identification card
Licence/reference No:
Issued in the state of:
Australian Passport (current or expired in the last 2 years)
NON-SIGNATURE DOCUMENT
Birth certificate (or extract)
Proof of Australian citizenship or permanent residency
Overseas Passport (current)
Country of issue:
LIST 2
SIGNATURE DOCUMENT
Pension Concession card/Department of Veterans’ Aairs
Entitlement card/Seniors Health card/Health care card/
any other current financial entitlement card issued by
Department of Human Services.
Credit card or bank card (do not attach copy)
Positive Notice Blue or Exemption card
Student identification card issued by an education
institution (with photo and signature)
Queensland Gaming Machine Licence
NON-SIGNATURE DOCUMENT
Medicare card
Queensland crowd controller/private investigator/
security ocer licence
Passbook or account statement issued by a financial
institution dated in the last 6 months
Australian taxation assessment notice dated in the
last 6 months
Queensland Licence issued under the Weapons Act 1990
If possible, please attach a photocopy of the documents sighted for verification purposes (excluding credit or bank cards).
Part F – Organisation declaration (to be completed by the organisation)
IMPORTANT NOTE: This section must be completed by the organisation's representative irrespective of whether or not the
organisation can sight the identification above.
I declare that:
• I understand that it is an oence to provide a false or misleading statement or document;
• I am authorised to submit this application on behalf of the organisation;
• the applicant is proposing to start or continue in regulated employment and an exemption does not apply;
• I have warned the applicant that it is an oence for a disqualified person to sign a blue card application (see page 4)
#
; and
• I have either:
checked the details provided in this form and confirmed they match those on the identification documents sighted; or
delegated this responsibility to a prescribed person and have attached the ‘Confirmation of identity’ form.
Note: It is an oence not to warn the applicant that it is an oence for a disqualified person to sign a blue card application.
Signature of representative
Date of signature
Name of representative
Position of representative
D D M M Y Y Y Y
Applicant’s name
Administrator
4
DJAG 001.V4 MAR19
Privacy Notice
The Department of Justice and Attorney-General (DJAG) is collecting your personal information under the Working with Children (Risk
Management and Screening) Act 2000 (WWC Act). Where relevant, DJAG will disclose personal information to organisations you work
for or provide services to about whether you have a current application for, or hold a current blue/exemption card; the outcome of this
application which may include its withdrawal or negative notice, or if your blue/exemption card is subsequently suspended or cancelled.
DJAG publishes confirmation about whether your blue card is valid. DJAG will use and disclose your personal information to assess your
application for a blue/exemption card and will disclose your personal information to courts, law enforcement agencies, disciplinary or
supervisory bodies or anyone you have agreed for DJAG to discuss your application with. It may also be used to contact you with more
information about your application and the Blue Card process. DJAG may use electronic communication for matters of information
provision and collection of data for research purposes. Authorised users of the home-based care register, kept pursuant to the WWC Act,
may also have access to your personal information. DJAG manages your personal information in accordance with the WWC Act and the
Information Privacy Act 2009.
Important information
You can withdraw your consent to screening at any time before a decision is made.
#
Disqualified person
It is an oence for a disqualified person to sign a blue card application form.
A disqualified person is someone who:
• has been convicted
^
of a disqualifying oence, which includes having sex with a child (irrespective of the type of relationship e.g.
teenage boyfriend/girlfriend, unlawful carnal knowledge), other child-related sex or pornography oences, murder and other serious
sexual or violent oences against an adult or child (irrespective of the penalty and regardless of when and where it occurred); or
• is the subject of:
reporting obligations or an offender prohibition order under the Child Protection (Offender Reporting and Offender Prohibition Order)
Act 2004; or
a disqualification order issued by a court prohibiting them from applying for or holding a blue card; or
a sexual offender order under the Dangerous Prisoners (Sexual Offenders) Act 2003; or
• is the respondent to an application for an oender prohibition order under the Child Protection (Oender Reporting and Oender
Prohibition Order) Act 2004.
*Non-conviction charge means, whether a person was charged as an adult or a child, a charge: that has been withdrawn; that has been
the subject of a nolle prosequi, a no true bill or a submission of no evidence to oer; that led to a conviction that was quashed on
appeal; or upon which a person was acquitted or disposed of by a court otherwise than by way of conviction.
^
Conviction/convicted means a finding of guilt by a court, or the acceptance of a plea of guilty by a court, whether or not a conviction is
recorded and regardless of when and where it occurred.
A disqualified person can apply to be declared eligible to apply for a blue card in certain limited circumstances.
Further information about disqualified persons is available from www.bluecard.qld.gov.au or by contacting Blue Card Services on
3211 6999 or 1800 113 611.
~Negative Notice
It is an oence for a negative notice holder to sign a blue card application form.
A negative notice holder is someone who:
• has been issued a negative notice after applying for a blue card; or
• was issued a negative notice after their blue card was cancelled due to a change in police or disciplinary information.
A negative notice holder can only apply to cancel a negative notice if two years have passed since the negative notice was issued, or in
other limited circumstances. This can be done by completing the Application to Cancel a Negative Notice form.
For more information about the blue card system and your obligations go to www.bluecard.qld.gov.au.
Application lodgement
Applications may be lodged by one of the following methods:
U
Scan and upload
www.bluecard.qld.gov.au/uploadform
By post
PO Box 12671, Brisbane George Street QLD 4003
In person
53 Albert Street, Brisbane QLD 4000
By fax
07 3035 5910
Fax
Fax
Fax
Applicant’s name
Blue Card Services, Department of Justice and Attorney-General
U
Scan and upload at www.bluecard.qld.gov.au/uploadform
PO Box 12671, Brisbane George Street QLD 4003
53 Albert Street, Brisbane QLD 4000
07 3211 6999 or 1800 113 611
07 3035 5910
www.bluecard.qld.gov.au
Fax
5
DJAG 001.V4 MAR19
-
i
Part G – Payment options for PAID employees only
The application fee is GST exempt (under division 81), non refundable and subject to change.
Payment is NOT required for volunteers or trainee students.
A $92.30 fee is required for paid employees. Please select one of the following payment methods:
Credit card—complete payment online at www.bluecard.qld.gov.au
Receipt number
Date payment made
D D M M Y Y Y Y
Cash or EFTPOS (over the counter transaction only)
Cheque/Money order—made payable to Blue Card Services (ABN 60 789 586 626)
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Completed 17 October 2020

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