From: g87@optusnet.com.au
Sent: Wednesday, September 30, 2015 8:31 AM
Subject: PRIVACY CONSENT FORM EX 29/September 2015
PRIVACY CONSENT FORM
PO Box 7576 Canberra Business Centre ACT 2610
Email Facsimile Telephone 1300 653 227
National Relay Service: TTY – 133 677, Speak and listen – 1300 555 727,
Internet relay – www.relayservice.com.au
www.dss.gov.au
COMPLAINT PRIVACY CONSENT FORM
I _____________________(name) give consent to the Department of Social
Services to disclose my personal information to any individuals or
organisations, including third parties, involved in the complaint for the
purposes of looking into and reporting on my complaint.
SIGNATURE ___________________________________________
DATE ___________________________________________
I also give my consent to any individuals or organisations involved in the
complaint to disclose my personal information to the Department of Social
Services for the purpose of looking into and reporting on my complaint by the
Department.
SIGNATURE ___________________________________________
DATE ___________________________________________
If you are under 18 years of age your parent/guardian will also need to
sign this on your behalf
Full name of parent/guardian
_________________________________________
Signature of parent/guardian
_________________________________________
Date _________________________
The Department of Social Services is collecting information about you to
assist in the effective management of your complaint as well as for training
purposes. The DSS Privacy Policy has been prepared in accordance with the
Australian Privacy Principles and contains information about how you can access
and correct personal information held by DSS about you. It also contains
information about how you can complain about a breach of the Australian Privacy
Principles and how DSS will deal with such a complaint. The DSS Privacy Policy
can be found on our website at www.dss.gov.au/privacy-policy.
PO Box 7576 Canberra Business Centre ACT 2610
Email Facsimile Telephone 1300 653 227
National Relay Service: TTY – 133 677, Speak and listen – 1300 555 727,
Internet relay – www.relayservice.com.au
www.dss.gov.au
COMPLAINT PRIVACY CONSENT FORM
I _____________________(name) give consent to the Department of Social
Services to disclose my personal information to any individuals or
organisations, including third parties, involved in the complaint for the
purposes of looking into and reporting on my complaint.
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