application for employmentwaratahprivate.com.au/wp-content/uploads/sites/2/2016/02/ehc-for… · a...

THIS DOCUMENT IS CONTROLLED

Document Number: EHC-FORM-HR15 of 20

Approved By: EHC Group Human Resources Manager Revision: 1 Dated: December 2015 Replaces Revision: 0

APPLICATION FOR EMPLOYMENT

Commencement Date: ______________________ Classification: _____________________________ Pay Code: _______________________________ Payroll No: _______________________________ Hours of Work Code: _______________________ Tax Code: _______________________________

* The application form will be available to, and must be completed by candidates if they are selected for an interview.

PERSONAL DETAILS: Surname: _______________________________________________________________________________________ Given Name/s: ___________________________________________________________________________________ Address: _________________________________________________________________Post Code: ____________ Telephone: (hm) ___________________ (bus) ______________________ (mob) ________________________ Email Address: _____________________________________________________________(for electronic pay advice) Date of Birth: ______________________________________________________ Position applied for:_______________________________________________________________________________ Date of application:________________________________________________________________________________ If successful with this Application, what date could you commencement employment?________________________ Type of Employment you are seeking? Full Time Part Time (no. of hours______) Casual Are you Legally Entitled to Work in Australia? Yes OR No Indicate your Current Work Rights*: Australian Citizen Permanent Resident Require Sponsorship

Holder of Working/Holiday Visa Holder of Student Visa Other I have completed the “Authority to Check Work Rights” form (see Appendix A)*: Yes N/A *NB: If you cannot provide evidence of work rights, or you are not a permanent resident of Australia, you must complete the Department of Immigration and Border Protection “Authority to Check Work Rights Form” (see Appendix A).

I have attached 100 Points of Identification in accordance with Appendix B**: Yes **NB: All candidates must provide 100 points of ID (see Appendix B).

Are you registered to practice unconditionally with AHPRA as an RMO / CMO / allied health / registered nurse / endorsed enrolled nurse / radiographer, pharmacist etc.?

Yes (attach copy of registration) No N/A

Position:

AHPRA registration number:

Practicing certificate anniversary

date:




Are you a licenced/certified tradesperson (e.g., plumber, electrician, chef etc.)?

Yes (attach copy of licence/certification) No N/A

Trade:

Registering body:

Trade licence number (original evidence must be sighted photocopy attached):

Are you a member of a Professional Organisation (CPA etc.)?

List any other countries where you hold current professional registration: _______________________________ Details of Education / Qualification

Level Attained Institution Year Attended

**Please attach copies of certificates and current practising certificates** EMPLOYMENT HISTORY (ATTACHED CV MAY BE PROVIDED IN LIEU OF COMPLETING BELOW)

Employer Position From To FT / PT / Casual

Reason for Leaving

I have completed the Service Declaration (Appendix F): Yes No *NB: If you are a nurse, health professional employee (all Allied Health practitioners, Social Workers etc.), Medical Officer, Allied Health Assistant, Wardsperson, CSSD technician you must completed (see Appendix F).




Have you undertaken and National Criminal History Record Check (“NCHRC”)?

Yes (attach) OR No* (I will obtain and attach) NB: The candidate will need to have undertaken and successfully satisfied the NCHRC requirements prior to an offer of employment being made. A satisfactory NCHRC is a mandatory requirement for appointment and ongoing employment.

If engaged directly from overseas, have you supplied an overseas Police Check (translated) or a Declaration (Appendix C- NSW or Appendix D – ACT)

Yes (attach) OR No (complete Appendix C (NSW) or D (ACT) OR N/A

Have you undertaken and Working With Children Check “WWCC” (or ACT Vulnerable Persons Check (VPC)?

N/A: NB: In NSW, a WWCC is required for all positions excluding administration, clerical or maintenance services, or ancillary services, if the work associated with the said services doesn’t involve unsupervised contact with children for extended periods (e.g. staff at SCP, some administrative roles, CSSD, short term maintenance contractors etc.). All positions in ACT are required to have undertaken a VPC.

YES: please provide your WWCC Clearance Number (WWC) or Application Number (APP) or Registration Card (ACT).

NOTE: The WCC and APP numbers will be 7 digits in length (NSW)

WCC/VPC No.__________________________________

APP__________________________________________

Date of WWCC/VPC_____________________________

Date of WWCC/VPC__________________________________

Expiry: WWCC (5 years) and VPC (3 years)

No: If the position requires the candidate to have a WWCC clearance, the candidate is required to go to http://www.kidsguardian.nsw.gov.au/working-with-children/working-with-children-check to make an application online or calls NSW Office of the Children’s Guardian on (02) 9286 7219. A WWCC clearance must be provided before the candidate will be considered for employment.

ACT candidates go to: https://www.accesscanberra.act.gov.au/app/answers/detail/a_id/1804 for details on how to apply.

Have you previously worked for this facility or any other Evolution Healthcare Facility?

Yes No

Information (when/facility etc.)

Do you hold a current Australian motor vehicles licence (for driving positions only)?

Yes (please provide details) No N/A

Licence No:

Class Type:

I have read the position description and have completed Appendix E (Health Declaration): Yes I have read and completed Appendix G (Health Record): Yes I have read and completed Appendix H (TB Assessment): Yes I have read and completed Appendix I (Latex Allergy): Yes

https://www.accesscanberra.act.gov.au/app/answers/detail/a_id/1804

https://www.accesscanberra.act.gov.au/app/answers/detail/a_id/1804




RECENT EMPLOYEE REFERENCES

In listing your referees, you are consenting to Evolution Healthcare contacting your referees as part of the recruitment and selection process

Referee 1

Name: ____________________________________________________________________________

Position Title: ____________________________________________________________________________

Phone Number (mobile phone number is not acceptable): __________________________________________________

Referees employer: ____________________________________________________________________________

Referee 2

Name: ____________________________________________________________________________

Position Title: ____________________________________________________________________________

Phone Number (mobile phone number is not acceptable): __________________________________________________

Referees employer: ____________________________________________________________________________

Conditions associated with this application:

The referees have been advised that that they have been nominated to support this application and I consent to them being contacted in regard to this application.

By signing this document, you authorise Evolution Healthcare to contact any academic institutions/professional bodies to verify the academic qualifications, certifications, memberships, licenses or registrations outlined in this application.

I am aware that I may undergo several screening processes to ascertain my suitability for the position for which I have applied, including:

one or more interviews;

a NCHRC;

a work rights status check;

a WWCC (where applicable);

reference checks (x2);

an assessment of my capacity to carry out the inherent requirements of the position;

Psychometric testing.

I acknowledge that Evolution Healthcare will:

release information on, and in association with this application form to nominated individuals participating in

the recruitment; and

retain this information in accordance with the Privacy Act 1988 (as amended). Name: __________________________________________________________

Signature: __________________________________________________________

Date: __________________________________________________________




Recruitment and Selection Checklist

NB: All Pre-recruitment documentation (below) MUST be completed before an offer of employment is made, and a contract of employment drafted). See the Staff Recruitment, Selection and Appointment Policy for the Post Recruitment documentation requirements.

DOCUMENT

YES NO N/A FOLLOW UP/PENDING

Application for Employment (checklist completed)

Current CV

Position Description

Working With Children (or Vulnerable People ACT) Check (where applicable)

National Criminal History Record Check

Authority to Check Work Rights Check (VEVO check to be completed) – Appendix A

100 Points of Identification – Appendix B

Current Registration (Unconditional) or Trade Licence

Job Description

Criminal History Record Check – Statutory Declaration (Appendix C –NSW or Appendix D – ACT)

Staff Health Declaration – Appendix E

Service Declaration - Appendix F (NSW & ACT)

Health Record – Appendix G

TB Screening Tool – Appendix H

Latex Allergy – Appendix I

Food Handlers Declaration (ACT only)

Interview Form(s)

Reference Check (x2)

If selected, Post-recruitment documentation to be forwarded to employee (see Staff Recruitment, Selection and Appointment Policy)

Name of person completing form: ________________________________________________________________ (please print) Signature: ________________________________________________________________

Date: ________________________________________________________________




APPENDIX A AUTHORITY TO CHECK WORK RIGHTS

The Australian Department of Immigration and Border Protection requires that we verify potential workers'

work entitlements prior to commencement. The check verifies:

1. Your entitlement to work in Australia legally. (Please provide the following):

Full name: ___________________________ Date of birth: _____________________________

Passport number: _____________________ Passport country of origin: ____________________

Visa Type and Subclass: ____________________________________________________(if known)

2. That at the time of the check being done, you are in Australia but are not entitled to be in the country

(the Commonwealth may use this information to locate you).

Please sign your consent for Evolution Healthcare to undertake a verification of your work entitlement on

the Visa Entitlement Verification Online (VEVO) system:

________________________________________

Signature

__________________________________

Date




APPENDIX B 100 POINTS OF ID

Instructions: 1. The 100 point identification check must be completed prior to lodgment of a National Criminal Record

Check or Working With Children background check. 2. Employers are required to sight original identifying documents, certify a photocopy which is to be

retained on the applicant’s personnel file, and ensure that an appropriately delegated officer completes the record of identifying documents below.

3. One primary document must be submitted from section (A) which is 70 points and other

documents from section (B) which make up the 30 points. 4. The point score of documents produced must total at least 100 points, and for applicants 18 years

or over, must include at least one form of photo ID. 5. If the compulsory document from section A indicates that the person may not be an Australian

citizen or permanent resident e.g. was born overseas or does not hold an Australian or New Zealand passport, the candidate will be required to complete Appendix A – Authority to Check Work Rights and the managers must complete a VEVO check.

Applicant’s Name:

ITEM POINT SCORE

(A) Primary Documents – Only one must be submitted

• Birth Certificate

• Birth Card issued by the New South Wales Registry of Births, Deaths and Marriages

• Citizenship Certificate

• Current Passport • Expired passport which has not been cancelled and was current within

the preceding 2 years

70

(B) Secondary Documents

The following documents must have a PHOTOGRAPH and NAME:

• Driver Licence issued by an Australian State or Territory

• Licence or permit issued under a law of the Commonwealth, a State or Territory Government (e.g. a boat licence)

• Identification card issued to a public employee • An identification card issued by the Commonwealth, a State or Territory

as evidence of the applicant’s entitlement to a financial benefit • An identification card issued to a student at a tertiary education institution

• A Proof of Age Card or NSW Photo Card issued by the NSW Roads and Traffic Authority.

40




ITEM POINT SCORE

The following documents must show NAME and ADDRESS:

• A document held by a cash dealer giving security over the applicant’s property

• A mortgage or other instrument of security held by a financial body

• Council rates notice

• Document from the applicant’s current or former employer within the past 2 years

• Document from the Credit Reference Association of Australia

• Land Titles Office record

35

The following documents must show NAME and SIGNATURE – points from the same source may only be counted once (ie. a Mastercard and EFTPOS card issued by the same financial institution):

• Marriage Certificate (for maiden name only)

• Credit Card (once sighted and photocopied, card no should be blacked out on copy before filing)

• Foreign Driver’s Licence

• Medicare Card (signature not required)

• Membership card for a registered club

• NRMA Membership

• EFTPOS Card

25

The following documents must show NAME and ADDRESS: • The electoral roll compiled by the Australian Electoral Commission and

available for public scrutiny • A recent signed reference of recommendation from an acceptable referee

(eg doctor, teacher, clergy, banker, police etc) • Lease/rental agreement

• Rent receipt from a licensed real estate agent

• Records of a public utility – eg. telephone, water, gas or electricity bill)

• Records of a financial institution

• A record held under law other than a law relating to land titles

25

The following documents must show NAME and DATE OF BIRTH: • The records of a primary, secondary, or tertiary institution attended by

the applicant within the past 10 years • The records of a professional or trade association of which the applicant is

a member

25




Record of identifying documents: Please record relevant details in the table below:

Description of document

Date of Issue

Place/ Office of issue/ issuing organisation

Expiry date

Ref. or doc. number

Points

Total points

Name and position of officer sighting documents

NOTE: This 100 point identification is adapted to accord with the Commonwealth Financial Transaction Reports Act 1988 as required by the CrimTrac Agency.




Appendix C (NCHRC – NSW)

Statutory Declaration

OATHS ACT 1900, NSW, NINTH SCHEDULE

1) I do hereby solemnly declare and affirm that I (please tick):

a. do not have any criminal convictions / pending charges in my country of origin or any country outside of Australia, which I have resided in or been a citizen of since turning 16 years of age; or

b. have listed below any criminal convictions / pending charges in my country of origin or any country outside of Australia, which I have resided in or been a citizen of since turning 16 years of age:

Date of conviction charge Details pending charge Country Penalty/Sentence

[the facts to be stated according to the declarant’s knowledge, belief, or information, severally]

And I make this solemn declaration, as to the matter (or matters) aforesaid, according to the law in this behalf made – and subject to

the punishment by law provided for any wilfully false statement in any such declaration.

Declared at: .............................................................................. on ................................................................................................. [place] [date]

............................................................................................... [signature of declarant]

in the presence of an authorised witness, who states:

I, .................................................................................................. , a ................................................................................................ , [name of authorised witness] [qualification of authorised witness]

certify the following matters concerning the making of this statutory declaration by the person who made it: [* please cross out any

text that does not apply]

1. *I saw the face of the person OR *I did not see the face of the person because the person was wearing a face covering, but I

am satisfied that the person had a special justification for not removing the covering, and

2. *I have known the person for at least 12 months OR *I have confirmed the person’s identity using an identification document and the document I

relied on was …………...………………………………….

[describe identification document relied on]

........................................................................................ ................................................................................................ [signature of authorised witness] [date]

NOTE: Oaths may be taken before a Justice of the Peace (JP). The JP must record their JP number as well as the information required above.




Appendix D (ACT)

Commonwealth of Australia

STATUTORY DECLARATION

Statutory Declarations Act 1959 1 Insert the name,

address and occupation of person making the declaration

I,1

make the following declaration under the Statutory Declarations Act 1959:

2 Set out matter

declared to in numbered paragraphs

2

2) I do hereby solemnly declare and affirm that I (please tick):

a. do not have any criminal convictions / pending charges in my country of origin or any

country outside of Australia, which I have resided in or been a citizen of since turning 16 years of age; or

b. have listed below any criminal convictions / pending charges in my country of origin or any country outside of Australia, which I have resided in or been a citizen of since turning 16 years of age:

Date of conviction charge

Details pending charge Country Penalty/Sentence

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular.

3 Signature of person making the declaration

3

4 Place 5 Day 6 Month and year

Declared at 4 on 5 of 6 Before me,

7 Signature of person before whom the declaration is made (see over)

7

8 Full name, qualification and address of person before whom the declaration is made (in printed letters)

8

Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4

years — see section 11 of the Statutory Declarations Act 1959.

Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 — see section 5A of the Statutory

Declarations Act 1959.




A statutory declaration under the Statutory Declarations Act 1959 may be made before–

(1) a person who is currently licensed or registered under a law to practise in one of the following occupations:

Chiropractor Dentist Legal practitioner

Medical practitioner Nurse Optometrist

Patent attorney Pharmacist Physiotherapist

Psychologist Trade marks attorney Veterinary surgeon

(2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described); or

(3) a person who is in the following list:

Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public

Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)

Bailiff

Bank officer with 5 or more continuous years of service

Building society officer with 5 or more years of continuous service

Chief executive officer of a Commonwealth court

Clerk of a court

Commissioner for Affidavits

Commissioner for Declarations

Credit union officer with 5 or more years of continuous service

Employee of the Australian Trade Commission who is:

(a) in a country or place outside Australia; and

(b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and

(c) exercising his or her function in that place

Employee of the Commonwealth who is:


(b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and


Fellow of the National Tax Accountants’ Association

Finance company officer with 5 or more years of continuous service

Holder of a statutory office not specified in another item in this list

Judge of a court

Justice of the Peace

Magistrate

Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961

Master of a court

Member of Chartered Secretaries Australia

Member of Engineers Australia, other than at the grade of student

Member of the Association of Taxation and Management Accountants

Member of the Australasian Institute of Mining and Metallurgy

Member of the Australian Defence Force who is:

(a) an officer; or

(b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or

(c) a warrant officer within the meaning of that Act

Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants

Member of:

(a) the Parliament of the Commonwealth; or

(b) the Parliament of a State; or

(c) a Territory legislature; or

(d) a local government authority of a State or Territory

Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961

Notary public

Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postal services to the public

Permanent employee of:

(a) the Commonwealth or a Commonwealth authority; or

(b) a State or Territory or a State or Territory authority; or

(c) a local government authority;

with 5 or more years of continuous service who is not specified in another item in this list

Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made

Police officer




Registrar, or Deputy Registrar, of a court

Senior Executive Service employee of:


(b) a State or Territory or a State or Territory authority

Sheriff

Sheriff’s officer

Teacher employed on a full-time basis at a school or tertiary education institution




APPENDIX E

Health Declaration

I,_________________________________________ have read the position description for the position I am applying for and (tick one of the following):

I am not aware of any health condition which might interfere with my ability to perform the inherent job requirements and job demands of this position.

I have a health condition that may require the employer to provide me with services or facilities (adjustments) so that I can successfully carry out the inherent job requirements and job demands of the position.

I understand that adjustments to the workplace can be made to assist employees with disabilities in carrying out the inherent job requirements and job demands of the position. Any adjustments I need have been discussed with the organisation prior to completing this health declaration.

I no longer wish to be considered for this position. I am aware that any false or misleading information may threaten my employment. Signature of applicant: _______________________________________ Date: ________________




APPENDIX F – SERVICE DECLARATION (NSW & ACT)

Commonwealth of Australia

STATUTORY DECLARATION

Statutory Declarations Act 1959 1 Insert the name,

address and occupation of person making the declaration

I,1

make the following declaration under the Statutory Declarations Act 1959:

2 Set out matter

declared to in numbered paragraphs

2

1) I, (name) ......................................................... of (address) ....................................................

in the State of New South Wales / ACT (please circle), do solemnly and sincerely declare that the

following information outlines my years of service as a (position held e.g. RN, EN, EEN, AIN, Allied Health,

Wardsperson, porter etc)………………………………………………………...............

2) I have previously been paid as a .................. year ………………………. and have attached either (please tick

appropriate box);

recent pay slip outlining hourly rate and classification as defined above

or

a letter from previous employer outlining my rate of pay and classification (in relation to my years of service)

ONLY IF THE ABOVE INFORMATION IS NOT AVAILABLE, PLEASE COMPLETE THE FORM OVERPAGE

DETAILING ALL EMPLOYMENT DATES

3) I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular.

3 Signature of

person making the declaration

3

4 Place 5 Day 6 Month and year

Declared at 4 on 5 of 6 Before me,

7 Signature of person before whom the declaration is made (see over)

7

8 Full name, qualification and address of person before whom the declaration is made (in printed letters)

8

Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4 years — see section 11 of the Statutory Declarations Act 1959. Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 — see section 5A of the Statutory Declarations Act 1959.




A statutory declaration under the Statutory Declarations Act 1959 may be made before–

(1) a person who is currently licensed or registered under a law to practise in one of the following occupations:

Chiropractor Dentist Legal practitioner

Medical practitioner Nurse Optometrist

Patent attorney Pharmacist Physiotherapist

Psychologist Trade marks attorney Veterinary surgeon

(2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described); or

(3) a person who is in the following list:

Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public

Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)

Bailiff

Bank officer with 5 or more continuous years of service

Building society officer with 5 or more years of continuous service

Chief executive officer of a Commonwealth court

Clerk of a court

Commissioner for Affidavits

Commissioner for Declarations

Credit union officer with 5 or more years of continuous service

Employee of the Australian Trade Commission who is:


(b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and


Employee of the Commonwealth who is:


(b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and


Fellow of the National Tax Accountants’ Association

Finance company officer with 5 or more years of continuous service

Holder of a statutory office not specified in another item in this list

Judge of a court

Justice of the Peace

Magistrate

Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961

Master of a court

Member of Chartered Secretaries Australia

Member of Engineers Australia, other than at the grade of student

Member of the Association of Taxation and Management Accountants

Member of the Australasian Institute of Mining and Metallurgy

Member of the Australian Defence Force who is:

(a) an officer; or

(b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or

(c) a warrant officer within the meaning of that Act

Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants

Member of:

(a) the Parliament of the Commonwealth; or

(b) the Parliament of a State; or

(c) a Territory legislature; or

(d) a local government authority of a State or Territory

Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961

Notary public

Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postal services to the public

Permanent employee of:


(b) a State or Territory or a State or Territory authority; or

(c) a local government authority;

with 5 or more years of continuous service who is not specified in another item in this list

Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made

Police officer




Registrar, or Deputy Registrar, of a court

Senior Executive Service employee of:


(b) a State or Territory or a State or Territory authority

Sheriff

Sheriff’s officer

Teacher employed on a full-time basis at a school or tertiary education institution

Name of Employer Date Commenced

Date Ceased

Speciality Area or Ward

Title FT/PT/Cas No of Hrs Worked (nominal hours not including overtime)

Note: If your service includes Agency Nursing or Casual work, total hours worked must be recorded and

verified if possible. You must total the number of hours you have worked in all your positions.




Appendix G

HEALTH RECORD

Name:_________________________________________ Date:_____________________________ Clinical applicants must provide acceptable evidence against the specified infectious diseases listed below before employment will be offered.

Diphtheria, tetanus, pertussis

Hepatitis B

Varicella

Measles, mumps, rubella The only exception is where a full course of a Vaccine has not yet been completed, then you must provide documented evidence that you have received at least the first dose and then provide the post vaccination serology result within 6 months of employment. All vaccinations/pathology is to be attended in your own time and at your own cost. Acceptable documentary evidence of protection against specified infectious diseases includes:

a written record of vaccination signed by the medical practitioner, and/or serological confirmation of protection, and/or other evidence, as specified in the table below.

Disease Evidence of Vaccination Documented

serology results Other acceptable evidence

Diphtheria, tetanus, pertussis (whooping cough)

One adult dose of diphtheria/ tetanus/ pertussis vaccine (dTpa). Not ADT.

Serology will not be accepted

Not applicable

Hepatitis B History of completed age-appropriate course of hepatitis B vaccine. Not “accelerated” course

Anti-HBs greater than or equal to 10mIU/mL

Documented evidence of anti- HBc, indicating past hepatitis B Infection

Measles, mumps, rubella (MMR)

2 doses of MMR vaccine at least one month apart

Positive IgG for measles, mumps and rubella

Birth date before 1966

Varicella (chickenpox) 2 doses of Varicella vaccine at least one month apart (evidence of one dose is sufficient if the person was vaccinated before 14 years of age)

Positive IgG for Varicella

History of chickenpox or physician- diagnosed shingles (serotest if uncertain)




Appendix H

Tuberculosis (TB) Assessment Tool

Staff will require TST screening if they were born in a country with a high incidence of Tuberculosis, or have resided for a

cumulative time of 3 months or longer in a country with a high incidence of TB as listed on the back of this form. It is recommended

that staff who meet the ‘high risk country’ criteria are to personally contact their nearest Public Hospital chest clinic and make an

appointment for the appropriate TST screening. Any staff who attend a Public Hospital chest clinic for TST screening should provide

the documentation to the Director of Nursing for inclusion in their personnel file. Each individual staff member is responsible and

accountable to attend the chest clinic for TST screening and follow-up. If staff have previously had TST screening and have the

evidence, they should provide the documentation to the Director of Nursing for inclusion in their personnel file.

Clinical History

Cough for longer than 2 weeks Yes No

Please provide information below if you have any of the following symptoms:

Haemoptysis (coughing blood) Yes No

Fevers / Chills / Temperatures Yes No

Night Sweats Yes No

Fatigue / Weakness Yes No

Anorexia (loss of appetite) Yes No

Unexplained Weight Loss Yes No

Assessment of risk of TB infection

Were you born outside Australia?

Yes No

If yes, where were you born?

_______________________________________________

Have you lived or travelled overseas?

Yes No

Country Amount of time lived/ Travelled in country

___________________________ __________________

___________________________ __________________

___________________________ __________________

Have you ever had:

Contact with a person know to have TB?

If yes, provide details below Yes No

Have you ever had:

TB Screening Yes No

If yes, provide details below and attach documentation.

If you answered YES to any of the questions above, please provide details (attach documentation).

I declare that the information I have provided is correct

Name:____________________________________________________________________________________________

Signature:________________________________________ Date:_________________________________________




Appendix I

Latex Questionnaire

Name: ______________________________________

Date: ______________________________________

Have you ever been diagnosed with latex allergy?

Yes □ No □ Unknown □

Have you ever experienced a reaction to latex e.g. skin rash, hives itchy and runny eyes and nose?

YES □ NO □ Unknown □

Have you ever suffered from respiratory problems related to a latex allergy?


Have you ever had a skin reaction from tapes or sticky plaster?


Have you had a reaction after handling rubber products e.g. balloons?


Have you ever suffered a reaction after going to the dentist, e.g. itchy and runny eyes and nose?


Signature: ______________________________________