Form

Status Resolution Support Services Programme

Privacy notice and consent 1450
Department of Home Affairs

This Agreement is for people who are receiving, or will How will the Department safeguard my privacy?
receive, benefits under the Status Resolution Support Services
Your personal information is protected by law, including the
(SRSS) Programme. The SRSS Programme is for:
Privacy Act 1988. Important information about the collection,
• unaccompanied minors in alternative places of detention; use and disclosure (to other agencies and third parties,
• people who will be placed in community detention; including overseas entities) of your personal information,
• people who will be released from detention with temporary including sensitive information, is contained in form 1442i
visas; and Privacy notice. Form 1442i is available from the Department’s
• people who are in the community and are referred to website www.homeaffairs.gov.au/allforms/ or offices of the
service providers for assistance. Department. You should ensure that you read and understand
form 1442i before completing this Agreement.
Please read this Agreement carefully. If you need any
assistance in understanding this Agreement please talk to your
service provider or an officer of the Department of Home Why are we asking for your consent?
Affairs (the Department) who can arrange an interpreter for In order to participate in the SRSS Programme, the
you. Department needs to use and disclose your personal
information, and sensitive personal information with
Am I eligible? contracted service providers and Human Services so that they
can provide you with the supports, services and payments on
The SRSS Programme provides eligible people with a range of
behalf of the Department. This will require you to complete
support services through contracted service providers and the
this Agreement.
Australian Government Department of Human Services
(Human Services), including case worker and financial
support. What happens to the information provided to the
Eligibility for support services under the SRSS Programme is service provider and Human Services?
decided on a case-by-case basis. If you are in held detention, The Department’s contracted service providers and Human
completing this Agreement does not guarantee you will be Services are also required to only collect, use and disclose
released from detention. your personal information in accordance with the Privacy Act
1988. They are required to keep your personal information
What personal information will be collected and securely and limit access to those staff with a business need to
know. You can get more information about the way in which
disclosed? Human Services will manage your personal information,
During interviews, case officers and International Health and including the privacy policy at
Medical Services (IHMS) collected personal and sensitive www.humanservices.gov.au/privacy or by requesting a
personal information from you. This information may be copy from Human Services.
provided to community service providers to help them plan
The Department will only provide service providers and the
and manage your placement in the community. Your
staff of Human Services enough information to ensure you are
information will also be provided to Human Services for the
provided with the appropriate services, supports and
purposes of administering payments under the SRSS
payments you are eligible for.
Programme. The information may include:
• personal information:
–– contact details
–– income and assets, including information about cash and
property you have in detention
–– immigration status
–– employment
–– education
–– language, and
–– accommodation including any support or
accommodation available to you in the Australian
community.
• sensitive personal information:
–– ethnicity
–– religion
–– details of your family members and other information
about their circumstances, and
–– health needs.

© COMMONWEALTH OF AUSTRALIA, 2018 1450 (Design date 03/18) - Page 1

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 Form
Status Resolution Support Services Programme
Privacy notice and consent 1450
Department of Home Affairs

The Department of Home Affairs (the Department) needs to OR if a person is unable or unwilling to release the information, a
collect your personal and sensitive personal information to guardian (if appointed) can deem the release of the information if it is
perform functions under the Migration Act 1958 and to provide in the best interest of that person
you with support services under the Status Resolution Support
Services (SRSS) Programme.
Signature of
Your personal and sensitive personal information will be
treated confidentially and will only be used and/or disclosed in
guardian -
accordance with your consent and/or the provisions of the DAY MONTH YEAR
Migration Act 1958 and Privacy Act 1988. For more Date
information about privacy please call 131 881.
Full name of guardian (block letters)
Please open this form using Adobe Acrobat Reader.
Either type in the fields provided or print this form and
complete it using a pen and BLOCK LETTERS. Organisation
Tick where applicable 3

1 Individual’s full name 3 Witness

• I saw the person sign their signature.
Family name
• I agree to not disclose any information contained in this Agreement.
Given names
Signature of
DAY MONTH YEAR witness -
Date of birth DAY MONTH YEAR

Person’s ID Date

ImmiCard number Full name (block letters)

(if applicable)

2 Consent
• I consent to participate in the SRSS Programme. I understand that to 4 Was an interpreter used?
participate in the SRSS Programme, the Department needs to provide No
my personal and sensitive personal information to contracted service Yes Give details
providers and the Department of Human Services. Personal and
sensitive information includes medical information and information Interpreter’s full name (block letters)
about my ethnicity and preferred language.
• I give consent to International Health and Medical Services (IHMS)
TIS number
to release my medical records and reports to the Department
and contracted service providers for the consideration of suitable • I have accurately interpreted the contents of this Agreement to the
placement in the community. person and checked their understanding prior to them signing.
• I understand I can withdraw my consent at any time by contacting • I am aware of the confidentiality clause under which I have been
the Department however, I understand that this would have an impact engaged and agree to not disclose any information contained in this
on the services provided to me. I understand that this consent will Agreement.
remain valid unless I withdraw it, even if I move into different bands
of the SRSS Programme. Signature of

Signature of
interpreter -
individual - Date
DAY MONTH YEAR

DAY MONTH YEAR

Date

© COMMONWEALTH OF AUSTRALIA, 2018 1450 (Design date 03/18) - Page 3