SSBA Reporting Forms: Change of Responsible Officer Details

Use this form to report changes to the Responsible or Deputy Responsible Officer or their contact details.

Page last updated: 24 July 2014

SSBA Reporting Forms List

Release Date: July 2014

Introduction

Facilities must report changes to Responsible Officer(s) details to the Department of Health (Health) as soon as possible and within two business days of the change occurring.

Providing information to Health

The information you provide to Health is mandated by the National Health Security Act 2007 and will be included on the National Register.

It is important to answer all questions and to provide accurate information. If the information you provide is incorrect or incomplete, Health may require you to provide additional information. This may cause delays.

Privacy

Personal information provided to Health will comply with the requirements of the Privacy Act 1988.

Application Authorisation

Please ensure that the person completing this form holds the appropriate authority to submit this application on behalf of the entity or facility.

Instructions on completing this form

This document allows electronic entry of information into the required fields. It is recommended that, where possible, this form should be completed on a computer and a copy printed, signed and sent to Health.

All questions are mandatory and must be completed. If the space provided in each field is not sufficient to complete your answer, please include any additional information in an attachment with the information clearly marked as to which question it relates to.

Please ensure you retain a copy of this completed form as Health is unable to provide copies of submitted documents.

Lodgement

To lodge this form via post you will need to use an opaque envelope and post using Australia Post’s Registered Mail service. You are considered to have submitted the report at the date and time shown on the registered post receipt.

Please do not email or fax forms to Health as these cannot be accepted.

Please submit all postal applications to:

The Director
Health Emergency Countermeasures Section
Department of Health
MDP 140, GPO Box 9848
Canberra ACT 2601

Once Health has received the form, you will be provided with a confirmation of receipt by email to the contact officer listed for the facility.

Further Information

Please use your facility reference number to refer to any matters relating to your facility.

If you have any queries about this form please contact the SSBA Regulatory Scheme:

Telephone: (02) 6289 7477
Email: SSBA

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Part 1: Facility Details

Please complete the details for the entity and facility.

Facility registration number
Entity name
Facility name

Part 2: Change of Responsible Officer Details

Please complete the new details for the Responsible Officer or Deputy Responsible Officer.

Responsible Officer Name
Title (Dr, Mr, Ms etc)

 

First Name

 

Middle Name  
Last Name

 

Contact Details
Business telephone number  
Mobile or emergency telephone number  
Facsimile (if applicable)  
Email  
Responsible Officer Postal Address (if different from the facility)
Address  
Suburb/City  
Postcode  
Deputy Responsible Officer Name
Title (Dr, Mr, Ms etc)  
First Name  
Middle Name  
Last Name  
Contact Details  
Business telephone number  
Mobile or emergency telephone number  
Facsimile (if applicable)  
Email  
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Part 4: Signature

The information collected on this form may be used by the Department of Health to decide whether to vary the National Register of Security Sensitive Biological Agents (National Register). If a decision is made to vary the National Register, the information contained on this form, including personal information, will be recorded on the National Register by Health.

The information collected on this form is authorised under the National Health Security Act 2007 and National Health Security Regulations 2008. Information collected on this form may be disclosed by Health to the Australian Security Intelligence Organisation, law enforcement agencies such as the Australian Federal Police and State and Territory police forces, other agencies responsible for responding to emergencies and other specified persons. The Department is unlikely to disclose personal information to overseas recipients.

Health has an Australian Privacy Principles (APP) privacy policy which you can read. You can obtain a copy of the APP privacy policy by contacting Health by telephone on (02) 6289 1555, freecall 1800 020 103 or by using the online enquiries form.

The National Register is hosted and maintained by the Attorney-General’s Department.

I declare that:

  • I am duly authorised to sign this declaration on behalf of the entity associated with this facility;
  • The information supplied on this form and any attachment is true and correct; and
  • This entity is compliant with the SSBA Standards currently in force.
Signature
Date
Full name (Please print)
Position title
Contact telephone number
Contact e-mail address
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