Client / Patient Details Surname: Given name: Date of birth: Home address: Email: Phone: Date of QEC admission: Information requested (provide as much detail as possible) This request relates to Historical Forced Adoption ☐ Yes ☐ No (For mothers and people who were adopted seeking access to hospital records as outlined in the 2021 Inquiry into Responses to Historical Forced Adoption in Victoria.) Is request on behalf of a third party: ☐ Yes ☐ No Are you acting on behalf of the client? If YES, please attach client’s written permission to obtain information on their behalf Is the client deceased? If YES, please provide evidence that you are next of kin Do you hold Power of Attorney or Guardianship for client? If YES, please provide evidence Company name: If relevant Surname: Given name: Date of birth: Address: Email: Phone: Relationship to client: All applications must be accompanied by proof of identity: Photo identification: driver’s license or passport If photo ID is not available then 3 other forms of ID are required: Medicare Card, Birth Certificate, etc. Minimum FOI application fee is $32.70. Please contact us if you wish to seek a payment exemption. Please submit your application form to QEC Freedom of Information Office via email foi@qec.org.au

FOI Access Request Form More information about your rights under the Freedom of Information Act can be found at the Office of the Victorian Information Commissioner website Home - Office of the Victorian Information Commissioner (ovic.vic.gov.au). Please do not hesitate to contact us is you have any queries or concerns.

Declaration

I understand that my request will not become valid until this form is submitted and payment of application fee has been made.

I understand that further to the application fee, additional administration / printing / photocopying charges may apply in respect to the application.

I understand that QEC Freedom of Information Office has up to 30 days to respond to this request.

Name:

Signature:

Date: