C2 Form

SECTION C2: OTHER INDEPENDENT PROFESSIONAL
1. APPLICANT TO COMPLETE – CONSENT TO DISCLOSE INFORMATION

In signing this form, I give consent for:
• the health professional or other professionals who have provided evidence or information in support of my application for a DES, including completing Sections C1
and/or C2, to disclose to the VCAA any relevant information about my illness/circumstances that has or may have affected my ability to attend or perform in my VCE
examination
• a health professional or other independent professional appointed by the VCAA, or staff of the VCAA, to obtain further details or evidence from any person who has
provided evidence in support of this application, if considered necessary by the VCAA
• the VCAA to use any information disclosed by a health professional/other professional as part of this application in the assessment of any future special examination
arrangements or derived examination score applications.
Signature Date / /
Full name
VCAA Student Number Date of birth D D / M M / Y Y Y Y

Section C2 must only be completed by the independent professional.
2. INDEPENDENT PROFESSIONAL TO COMPLETE

This section is to be completed by an independent professional who has specific knowledge of the personal trauma or serious intervening event suffered by the student
that affected their ability to perform in the VCE examination. The independent professional should be an independent social worker or member of a clergy. Alternatively,
for a serious intervening event, they may also be a police officer, solicitor or funeral parlour operator.
The professional must not be related to, or have a close personal relationship with, the student and must have been professionally associated with the student’s situation.
All related dates and events must be documented.
Newspaper death and funeral notices can be attached to this page. These notices must establish a clear and direct relationship between the deceased and the student.
The above ‘consent for disclosure’ authorises the independent professional to provide information to the VCAA that is relevant to the student’s application. This MUST be
signed by the student, or their parent/guardian where the student is a minor.
Note the following, for each examination for which a student applies for a DES:
• If the student attended the examination, the individual providing the independent evidence must have examined or treated the student or have been consulted
by the student in a timely period before or after the examination. It is expected that a timely consultation would occur in the period from two days before the
examination to one day after the examination.
• If the student did not attend the examination, the individual providing the independent evidence must have been consulted by the student in a timely period as
close as possible to the day before the examination or on the same day as the examination. In the case of a personal trauma or a serious intervening event,
there must be written evidence from an independent professional confirming the reasons why the student was unable to attend an examination.
Name
Occupation
Organisation
Email address
Telephone ( )
Student name
Date of birth D D / M M / Y Y Y Y
Are you professionally acquainted with the student? No Yes } If yes, how long? yr/s mth/s wk/s day/s
Are you personally acquainted with the student? No Yes } If yes, how long? yr/s mth/s wk/s day/s
1
Type of personal trauma/serious intervening event
Date of onset D D / M M / Y Y Y Y
Other professionals consulted by the student for this personal trauma/serious intervening event
Name
Occupation
Name
Occupation
How has this personal trauma or serious intervening event affected the student’s preparation and/or performance in the examination?
Signature Date / /
In signing this form I consent to the VCAA using the information I have provided in this application, including personal information, to assist with the assessment of any
future special provision applications that may be submitted on behalf of the student identified in this application.
This form MUST be signed by the applicant and the independent health professional.
Print
Collection Notice
The Victorian Curriculum and Assessment Authority (VCAA) is a statutory authority continued under the Education and Training Reform Act 2006 (Vic) (the Act). The VCAA
collects the information requested in this document, which includes personal information within the meaning of the Privacy and Data Protection Act 2014 (Vic) and may
also include personal and health information within the meaning of the Health Records Act 2001 (Vic), for the purpose of facilitating and administering an application for
a Derived Examination Score (DES) under s 2.5.11 of the Act. The personal and/or health information collected in this document will be disclosed to and used by VCAA
employees and/or contractors for and in connection with the abovementioned purpose. The personal and/or health information collected will not otherwise be used or
disclosed by the VCAA, except with the prior written consent of the individual, or if the VCAA is required or otherwise permitted by law to do so. When an individual’s
personal and/or health information is provided to the VCAA by a third party, the VCAA requests that the individual is made aware their personal and/or health information
will be or has been provided to the VCAA, the purpose for which it will be or was provided and to whom it will be or is likely to be disclosed. If all or part of the requested
information is not provided, the DES Application may not be considered. An individual may request access to personal and/or health information the VCAA holds about
them, and request its correction if inaccurate. Initial enquiries regarding access to personal and/or health information held by the VCAA in relation to DES Applications can
be made by contacting the Project Manager, Special Provision at vcaa.special.provision@education.vic.gov.au.
The VCAA Privacy Policy can be found at: www.vcaa.vic.edu.au/Footer/Pages/Privacy.aspx

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SECTION C2: OTHER INDEPENDENT PROFESSIONAL

1. APPLICANT TO COMPLETE – CONSENT TO DISCLOSE INFORMATION

VCAA Student Number Date of birth D D / M M / Y Y Y Y

2. INDEPENDENT PROFESSIONAL TO COMPLETE

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