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Witness Incident Form

DH1028


This form is to be used by a complainant or witness when reporting an incident relating to a Homes NSW tenancy. 

For information or assistance with this form, phone 1800 422 322, 24 hours a day, seven days a week.


Your details

Details of the person(s) you are complaining about

Details of incident

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Your right to privacy

DCJ Privacy Notice 

This notice outlines how the Department of Communities and Justice (DCJ) collects, uses, stores and discloses yourpersonal and or health information in accordance with the Privacy and Personal Information Protection Act 1998 (NSW)(PPIP Act) and the Health Records and Information Privacy Act 2002 (NSW) (HRIP Act). 

DCJ collects personal and or health information from time to time in connection with your application for housing services or during your tenancy for the purposes of assessing and processing your application for housing assistance and or administering your tenancy. 

We may also collect information to provide you with support services, related to your tenancy or as a client of DCJ. This information may be collected from: 

  • you directly

  • individuals who are visiting or residing at the same residential address as you 

  • members of the public

  • Community Housing Providers 

  • your authorised representatives 

  • other third parties, for example, medical practitioners 

  • other NSW or Commonwealth government agencies (as permitted by law). 

This information is held by DCJ, and where relevant, Community Housing Providers. The information held relates to services provided to you, including the details you provide in this document and information in other documentation completed or provided by or on your behalf, and it also relates to information you provide to our staff or Community Housing Providers (for example, during the sign-up process for your public housing tenancy). 

DCJ may also use your information for data analytics, data matching and data integration on DCJ’s Federated Analytics Platform (FAP). In addition to the use of your information on the FAP, this information will also support policy making, program and service planning, delivery of targeted services for clients, program evaluation, monitoring and reporting, research and resource planning. We may also use your information within DCJ to plan, coordinate and improve the way we provide services. This includes the use of information by companies contracted by DCJ, for example, for the purposes of determining client satisfaction and related long-term service enhancement. 

Intended recipients of your personal and or health information include those involved in the above activities, as well as any others who may have a lawful interest in considering your application or tenancy, including where relevant: 

  • DCJ 

  • Aboriginal Housing Office 

  • Community Housing Providers 

  • Housing Appeals Committee 

  • NSW Land and Housing Corporation 

  • The Minister administering the Housing Act 2001. 

DCJ may also disclose your personal and or health information where required or permitted by law, for example: 

  • for purposes relating to child protection, health reasons, protection of public revenue, and or law enforcement 

  • to relevant statutory bodies 

  • to other co-tenants, authorised occupants and or visitors of the subject residential address. 

The supply of your personal and or health information in this form is voluntary; however, if you do not supply us with the information we request, we may not be able to process your application, provide services to you or other individuals affected by your tenancy, or provide other forms of assistance. 

You have a right of access to, and correction of, your personal and health information held by DCJ in accordance withthe PPIP Act and the HRIP Act. Further information about your privacy rights are available on the DCJ website at https://dcj.nsw.gov.au/statements/privacy.html.

Consent and Authority

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Declaration

  • To the best of my knowledge, the information provided in this form is correct.

  • I understand there are penalties for giving false or misleading information.

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Declaration from person assisting witness/complainant

That person should read and sign the declaration below

  • I filled in this form on the basis of the information the complainant/witness gave me.

  • I have read out the form and the answers to the complainant/witness who seemed to understand them.

  • I understand there are penalties for giving false or misleading information.


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