Consent Form (Proposed Appointee/Interested Person)

CONSENT FORM (PROPOSED APPOINTEE/INTERESTED PERSON)

I, ,havemade an application to be considered for thelistofpractitionerseligibletobeappointedtoaMedicalPanelfortheperiod1July2016to30June2019and understandthattheMedicalPanels,theDepartmentofTreasuryandFinanceandtheVictorian Public Sector Commission maycollectandholdcertainpersonalinformationaboutmeincluding:

• mynameandaddress;

• mydateofbirthandage;

• mygender;

• whetherI liveinruralorregionalVictoria;

• whetherI identifyasanAborigineorTorresStraitIslander;

• whetherI ormyparentswereborninAustralia;

• whetherI speakalanguageotherthanEnglishathome;and

• whetherI haveaculturallydiversebackgroundotherthanthatindicatedinthepreviousquestions.

ThisinformationissubjecttotheInformationPrivacyPrinciples(IPPs)foundintheInformationPrivacyAct2000(IPAct).UnderIPP1,theMedicalPanelsandtheVictorian Public Sector Commissionmusttakereasonablestepstoensure thatIamawareof:

• thebody’scontactdetailsandhowtocontactit;

• thefactthatI amabletogetaccesstothatpersonalinformationaboutme;

• thepurposesforwhichtheinformationiscollected;

• towhomthatinformationisusuallydisclosed;

• anylawrequiringtheinformationtobe collected;and

• theconsequencesformeif theinformationisnotcollected.

IhavereadthenoticeunderIPP1.3whichisprovidedwiththisconsentform.

IamawareofthecontactdetailsfortheMedicalPanelsandtheVictorian Public Sector Commission.

I understand that I can seek access to personal information collected about me and can request the

Department/AgencyortheVictorian Public Sector Commission tocorrectandupdateit.

Purposeofcollection

Iunderstandthattheinformationis beingcollectedandusedto:

• processandassessmyapplicationforconsiderationoftheappointment;

• enabletheVictorianGovernmenttomonitorthediversityofappointmentstoandcompositionofstatutoryand otherbodiestowhichtheGovernmentmaymakeappointments;

• managedealingswithme(forexampletocontactmeortoprovidemewithotherinformationfromtimeto time);and

• beincludedintheVictorian Public Sector Commission’sappointmentsdatabase,asecuresystemforstoringinformation aboutpublicentitiesandmembersofpublicentityBoards,CommitteesandCouncils(thissystemismanaged bytheVictorian Public Sector Commissionandhostedona securegovernmentserver).

ForthesepurposesIunderstandthattheinformationisusuallydisclosedto:

• anyDepartmentandauthorisedofficersnominatedbytheSecretaryoftheDepartmentorhisorherdelegate;

• authorisedofficersoftheVictorian Public Sector Commission(nominatedbytheCEO oftheVictorian Public Sector Commissionorhis orherdelegate);

• theDepartmentofPremierandCabinetforuseonlyforthepurposesofannualreporting;

• theCabinetoranymemberofitforuseonlyforthepurposesofannualreporting;

• ifIconsent,(seebelow)mypersonalinformationmaybesharedforthepurposeofappointmentstoother publicsectorentityboardswithotherdepartmentsandagencies;and

• asotherwiseusedinaccordancewiththeIPAct.

Informationontheappointmentsdatabaseisusedforthefollowingpurposes:

•ToenabletheVictorianGovernmenttomonitorthediversity andprofileofappointmentstoandcomposition ofpublicsectorentityBoardstowhichtheGovernmentmaymakeappointments;

•ToallowtheVictorian Public Sector Commissiontouseinformationontheappointmentsdatabaseforresearchpurposes andtoplanimprovementstogovernanceprocessesforVictorianpublicsectorentityBoards;and

•ToallowtheVictorian Public Sector Commissiontodrawselectandlimitedinformation(describedbelow)fromthe appointmentsdatabaseandforthisselectandlimitedinformationtobe madepubliclyavailableona Victorian Governmentwebsite.

Iunderstandthat,forreasonsofpersonalsafety,thecompositionofsomepublicsectorentityBoardswillnot appearonaVictorianGovernmentwebsite,andthat Icandiscussthis withtheSecretaryofthe Departmentorhis orherdelegateif I thinkthisisrelevanttome.

Iunderstandthatmyrefusaltoconsenttothecollection anddisclosureofinformation describedinthisconsent formmayimpactonmybeingconsideredforanappointment andmayresultingreaterdifficultyfor Departments/Agenciesinmonitoringthediversityofboardappointmentsandtheircomposition.

Consent

IconsenttotheMedicalPanelsandtheVictorian Public Sector Commissioncollecting,usingandholdingthatinformation, and releasingittothe VictorianGovernmentDepartmentor DepartmentsorAgenciesresponsiblefor thatbodyin accordancewiththeIPActforthepurposesoutlinedinthisconsentform.

Iunderstandthatrecipientsofinformation aboutmeprovidedasaresultofthisconsentwillremoveasfaras practicableanypotentialmeansofidentifyingmeindividuallyundertheirreportingrequirements.

Iconsenttothefollowinginformationbeingmadepubliclyavailableina VictorianGovernmentwebsite:

•myfirstnameandsurname;

•thetermofmyappointment;and

•mystatusasamemberorchairperson.

Imayhaveprovidedinformationaboutotherindividualsinmycurriculumvitaeandanyotherdocumentation includedinmyapplication.IacknowledgethatwhenIprovidepersonalinformationaboutotherindividualssuch asreferees,theMedicalPanelsreliesonmetomakethoseotherindividualsawarethatsuchinformation willor maybeprovidedtotheVictorianGovernment,therelevantpurposesthatVictorianGovernmentwilluseitfor, andhowtheycanaccessit.

IwishtoadvisethatthefollowingrestrictionsapplytothedistributionoftheinformationI haveprovidedtoyou:

(insertrestrictions(ifany)whichapplyinrelationtotheinformationorspecificpartsofit)

Iagree/donotagree(crosswhichisnotapplicable)totheDepartment sharingmyinformationwithother VictorianGovernment Departments forthepurposesofenablingtherelevantMinistertoconsidermefor appointmenttootherboards.

Iwould/wouldnotlike(crosswhichisnotapplicable)toreceiveinformationabouttheDiversityRegister,a GovernmentinitiativethatactsasacentralcontactpointforallVictorianGovernmentDepartmentsseeking skilledindividualsforupcomingvacanciesonboardsandcommittees.

Signed:_

Date:

()(printname)

Witnessname:

WitnessSignature: _

Date:

NOTICEUNDERINFORMATIONPRIVACYPRINCIPLE1.3

TheIPActobligestheMedicalPanelstoadviseyouofcertainfactsregardingthecollectionandmanagement of informationrelevanttoyourappointmenttotheMedicalPanels.

Ifyouaccepttheappointment,theMedicalPanelsandtheVictorian Public Sector Commissionwillholdtheinformation aboutyou identifiedinthisconsentform.The informationwill becollectedand usedfor the purposesidentifiedin thisconsentformandwillusuallybedisclosedtothepersonsandbodiesidentifiedinthisconsentform.

Thisinformationisaccessibletoyouatanytime,andcanbeobtainedbymakingarequesttoMedicalPanels

1800061715andtheVictorian Public Sector Commission.

Theinformationcollectedandusedforthepurposesidentifiedinthisconsentformandwillnotbedisclosedto anyotherpersonorbodyotherthanthoseidentifiedinthisconsentform,orwhereauthorisedorrequiredbylaw.

TheMedicalPanelsand the Victorian Public Sector Commissionhaveimplementedtechnologyand securitypolicies,rules and measurestoprotectthepersonalinformationthatithasunderitscontrolfromunauthorisedaccess,improper use,alteration,unlawfuloraccidentaldestruction andaccidentalloss.TheMedicalPanelsandtheVictorian Public Sector Commissionwillremovepersonalinformation fromitssystemwhereitisnolongerrequired(exceptinaccordance withthePublicRecordsAct1973).

Refusaltoprovideandconsenttotheuseofthepersonalinformation soughtfortheappointment processmay resultingreaterdifficultyinmonitoringthediversityofboardandotherbodies’appointments andtheir composition.