Fields marked with an asterisk * are required to submit the form
Details of applicant
Details of data request
What information/data is required? (Please provide detailed description of the information you require to be disclosed.
For what purposes do you request this information? (Please provide details of the purpose of the data request, the intended uses and any derived benefits)
Which legislative provisions would authorise the disclosure of this information for the above identified purpose?
Acknowledgement, declaration and undertaking
- I acknowledge that I have read, understood, and agree to be bound by the QILT data protocols in the event that my request is approved.
- I declare that the information I have given on this form is true and correct in all regards.
- I undertake that any data received will be used only for the purpose for which it was provided.
- I undertake that any personal information received will be accessed only by those authorised to use it, and will not be disclosed to any party except where required or authorised by or under law.
- I undertake not to publish outside of the organisation I represent, in any medium, any material based on or including QILT data, without providing prior written notification to SRC.
- I acknowledge that a breach of the QILT data protocols or undertakings made on this data request form may result in the rejection of future requests for data submitted by me or by the organisation I represent.
SRC is collecting personal information on this form in order to process the data request detailed above. Only authorised employees of the SRC or the Department of Education will have access to this information. This information will not be disclosed to third parties unless consent is obtained or where the disclosure is required or authorised by or under law.