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GovtAgentAssessment - Form

This document is a questionnaire for a government agent to assess the legality of their investigation. It contains 25 questions for the agent about their identity, the scope of the investigation, and protections for the individual's privacy and property.

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67 views2 pages

GovtAgentAssessment - Form

This document is a questionnaire for a government agent to assess the legality of their investigation. It contains 25 questions for the agent about their identity, the scope of the investigation, and protections for the individual's privacy and property.

Uploaded by

jpes
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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GOVERNMENT AGENT LEGALITY ASSESSMENT

I, ………………………………………… of (address) ……………………………………………………………………..


reserve my responses, and regard my personal and business affairs as private and confidential, and any
request for disclosure MUST fully comply within the PRIVACY ACT AND ALL OF THE PROTECTIONS
ACTS with the completing and signing of this QUESTIONNAIRE, before this individual makes a
determination in diligence of information.

1. Name of Agent: …………………………………………………………………………………………………………..

Agent's Employment address: ……………………………………………………………………………………..

Town: …………..…………………… State: ………….. Post Code: …………..

2. Name of Government agency by which Agent is employed: ……………………………………………………….

Instructing Supervisors' name: …………………………………………………………………………………….

3. Department's postal address: …………………………………………………………………………………………..

NOTE: Boxes MUST be ticked either YES or NO.

4. Will the Agent uphold the Privacy Act, and all other Protection Acts? YES NO

5. Did the Agent supply proof of identity? YES NO

In what form is the proof of identity? (I/D card or similar) …………………………………………………..

Number: ………………… Badge Number: …………………Other: *………………………………………..

6. Will the Agent supply a copy of the Law or Regulation relied upon to
investigate? YES NO

7. Will the Agent recite the portion of Authority relied upon? YES NO

… and provide a written copy? YES NO

8. Are the questions being used as discovery? YES NO

If so, to what use? * ……………………………………………………………………………………………...

… or are they based on a specific Law or Regulation? YES NO

9. Are questions to be voluntary? …………………………………. or, mandatory? …………………………………

If mandatory, under what Act? * ………………………………………………………………………………

10. Will there be any other persons or entities using this information? YES NO

If YES, who, where and to what purpose? *…………………………………………………………………...

……………………………………………………………………………………………………………………...

11. What other agencies may have access to this information? * ……………………………………………………...

……………………………………………………………………………………………………………………...

12. Do you have a Crown Sealed Warrant? YES NO

If YES, did you allow me to contest the application when it was made? YES NO

13. Are you intending to trespass my property? YES NO

14. Are you intending to trespass my goods? YES NO

© Legal Assessment Document - April 2003 Page 1 of 2


GOVERNMENT AGENT LEGALITY ASSESSMENT (…continued) fnqind03

15. What will be the effect on me IF I should choose not to answer any part or all of the questions?…………….

………………………………………………………………………………………………………………………………...

16. The name of the person in Government under whose authority this investigation is being made? *…………

………………………………………………………………………………………………………………………………...

17. Is this investigation Random?………………….. General? ………………….. or, Special? ……………………….

By 'Random' is meant a luck of the draw - by 'General' a blanket investigation involving a number of persons
because of the "geography" type of business, income etc. - by 'Special' is meant an investigation of a singular
nature in which others are not involved.

18. Have you consulted, questioned, interviewed or received information


from a third party relating to this investigation? YES NO

19. If YES, the identity of the third party or parties? *…………………………………………………………………..

20. Do you reasonably anticipate either a civil or criminal action to be


initiated or pursued based upon any of the information that you seek? YES NO

21. Is there a file of records, or information, or correspondence relating to


me being maintained by this agency? YES NO

22. Is this agency using any information pertaining to me, which was
supplied by another agency or Government source? YES NO

If YES, provide details: *…………………………………………………………………………………………

23. Will the Agent guarantee that the information in these files will not be
used by any Department other than the one he/she is employed by? YES NO

24. Will I be discriminated against as a result of this Questionnaire? YES NO

25. Will questions asked be in writing? or oral?

26. What time will be allowed for my consideration before answering questions?

5 minutes 1 hour 7 days 14 days Other: ……………………..

Should any person or agency make a request for any information, obtained as a result of the
undersigned Agent's enquiries, you MUST inform me in writing BEFORE releasing such
information. Failure to comply may subject you to possible civil or criminal actions as provided
by law.

OATH OR AFFIRMATION BY THE AGENT


I swear (or affirm) the answers given to the foregoing questions are TRUE and CORRECT in every detail.

SIGNED: …………………………………………….. PRINT NAME: …………………………………………………...


(AGENT/OFFICER)
DATED:……………………………………………..

WITNESS: …………………………………………… PRINT NAME: …………………………………………………..


(RESPONDENT)
DATED:……………………………………………..

WITNESS: …………………………………………… PRINT NAME: …………………………………………………..


(SIGNED IN MY PRESENCE)
DATED:……………………………………………..

* If space is insufficient please supply details on an additional page and affix hereto.

© Legal Assessment Document - April 2003 Page 2 of 2

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