Application Form

DHS Screening

Application Form AP1826831 (Version: 1)

Referring Organisation DHS - Applicant Initiated
Applicant Name Hannah Mohsen Ismail

Screenings

Screening Number Screening Type

SC2021230 Working With Children 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 - SA.GOV.AU
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
- SA.GOV.AU

Your Personal Details

Title: Miss

Current Last name: Ismail Current First name: Hannah

Current Middle name: Mohsen

Reference Number: 87RJKYFACT

Gender: Female

Date of Birth: 31/01/2005 Town/city of birth: NORTH ADELAIDE

State/Territory of birth: SA Place of Birth: Australia

Do you identify as Aboriginal or Torres Strait Islander?

Your Previous Names

No Previous Names recorded

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Your current contact details

Unit No: Street: 21 BLIGH AVENUE

Suburb/town: PANORAMA State: SA Postcode: 5041

Period of residence From: 4/08/2014

Telephone: (H) (W) (M) 0426634909

Email address: hannah.ismail31@gmail.com

Current postal address: Postal Address same as Residential Address:

Unit No: Street: 21 BLIGH AVENUE

Suburb/town: PANORAMA State: SA Postcode: 5041

Your previous residential addresses

No Previous Addresses recorded

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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. 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?
9. 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)?
10. 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?
11. 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?
12. 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, Hannah Mohsen Ismail 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.

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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.
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.

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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).
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.

Do you agree and consent to the above? Yes No

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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 - SA.GOV.AU.

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
- SA.GOV.AU.

Applicant Full Name: Hannah Mohsen Ismail

Name of Verifying Officer: School Principal SAC ( St Aloysius College)

Organisation: School Principal

Position: Principal - Paddy McEvoy - SAC

Telephone: (W) (M) 0882173200

Email address: PMcEvoy@sac.sa.edu.au

Signature:

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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)

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Category
Category C Documents
25 points
If you wish to use more than
one Category C document,
they must be from different
organisations.
Must equal or be more than 100 Points
DO NOT attach copies of these documents to the application form.
AP1826831 (Version: 1)
Type of Document Value Points
Extract of a Birth Certificate
Proof of Age Card (GOVERNMENT ISSUED)
Medicare Card OR Private Health Card (ONE
ONLY)
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
TOTAL
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Employment Information

Employment/Placement/Volunteer Details

If the applicant is a prospective employee/student/volunteer, what is their proposed start date? 27/02/2024

Screening Unit Contact Details

Please email your completed application form to DHSScreeningUnit@sa.gov.au or post it to the Screening
Unit at GPO Box 292 ADELAIDE 5001.

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