SSBA Reporting Forms: Change of Entity and Facility Details

Use this form to change your entity or facility details. If you have physically moved your facility, please contact Health.

Page last updated: 12 May 2014

Release Date: April 2014

Introduction

Entities must advise the Department of Health (Health) of any changes to the administrative details of the entity or facility as soon as possible and within two business days of the change occurring.

Note: Please do not use this form if:

  • Details for the Responsible Officer or Deputy Responsible Officer have changed. This should be reported using the Change of Responsible Officer Report within two business days of the event occurring.
  • The facility has physically moved or the secure area has changed substantially. This may require a new registration. Please contact the SSBA Regulatory Scheme to discuss.

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 of SSBAs.

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 you hold the appropriate authority to submit this application on the behalf of the entity or facility. For a registered facility this may be the Responsible or Deputy Responsible Officer or an authorised person appointed by the Responsible or Deputy Responsible Officer.

Instructions on preparing this notification

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 marked with an * are mandatory and must be completed. Other fields are to be completed only if the information has changed.

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 you with 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 this form, you will be provided with a confirmation of receipt via email to the Responsible Officer for the facility.

Further Information

Please use your facility registration 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: Entity Details

Please complete the details for the entity and facility. All fields marked with an * are mandatory and must be completed.

*Facility registration number
*Entity name
*Facility name

Part 2: Change to Entity Details

Please only fill in the details of the entity that have changed. You are not required to fill in the fields where no changes have occurred.

Entity Details
Entity trading name (if different to above)
ABN
ACN
Australian Registered Body Number
Physical Address
Address 1
Address 2
Suburb/City
State
Postcode
Postal Address (if different from above)
Address 1
Address 2
Suburb/City
State
Postcode
Contact Details1
Telephone number
Facsimile number
Email address
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Part 3: Change to Facility Details

Please fill in the details of the facility that have changed. You are not required to fill in fields where no changes have occurred. If the facility has physically moved or the secure area has changed substantially, please contact Health.

Facility Details
Facility name
Postal Address
Address 1
Address 2
Suburb/City
State
Postcode
Contact Details2
Telephone number
Facsimile number
Email address
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Part 4: Signatures

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 the Department. The collection of personal information is authorised under the National Health Security Act 2007 and National Health Security Regulations 2008.

Information included on the National Register and other information collected on this form may be disclosed by the Department 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.

The Department has an Australian Privacy Principles (APP) privacy policy which you can read. You can obtain a copy of the APP privacy policy by contacting the Department 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.

All fields marked with a * are mandatory and must be completed

*Signature
*Date
*Full name (Please print)
*Position title
*Contact telephone number
*Contact e-mail address

  1. If the Responsible Officer or Deputy Responsible Officer has changed, please fill in a Change of Responsible Officer Report.
  2. If the Responsible Officer or Deputy Responsible Officer has changed, please fill in a Change of Responsible Officer Report.
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