application for employment - web viewword of mouth . other source (specify ) other newspaper...

APPLICATION FOR EMPLOYMENT

Application for Employment

Section A – Position DetailsA1: POSITION DETAILSWHICH POSITION ARE YOU APPLYING FOR? JOB REFERENCE NUMBER? EARLIEST DATE YOU CAN START?

Section B – Personal InformationA2: YOUR NAMES AND DATE OF BIRTHGIVEN NAMES SURNAME TITLE [MR, MRS, MS, MISS]

PREFERRED GIVEN NAME(S) [IF DIFFERENT] PREFERRED SURNAME [IF DIFFERENT] DATE OF BIRTH

.A3: PHYSICAL ADDRESSTREET NUMBER / NAME

SUBURB / TOWN STATE POSTCODE COUNTRY [IF NOT AUSTRALIA]

.A4: POSTAL ADDRESS [IF DIFFERENT TO PHYSICAL ADDRESS]POST OFFICE BOX OR STREET NUMBER / NAME

SUBURB / TOWN STATE POSTCODE COUNTRY [IF DIFFERENT]

.A5: OTHER CONTACT DETAILSMOBILE NUMBER WORK NUMBER HOME PHONE NUMBER WHICH NUMBER DO YOU PREFER US TO USE?

EMAIL ADDRESS (PRIMARY)

EMAIL ADDRESS (SECONDARY)

.A6: LANGUAGE AND NATIONALITYLANGUAGES SPOKEN [OTHER THAN ENGLISH] ARE YOU AN AUSTRALIAN CITIZEN OR PERMANENT RESIDENT?

Yes [If “Yes” skip remaining Nationality questions] No VISA TYPE / CLASS WORK CONDITIONS ISSUE DATE EXPIRY DATE COUNTRY

.A7: MOTOR VEHICLE DRIVING LICENCEDO YOU HAVE A CURRENT AUSTRALIAN DRIVING LICENCE? LICENCE NUMBER STATE OF ISSUE

Yes No [If “No” skip remaining driving questions] EXPIRY DATE CLASS TYPE CONDITIONS

Manual Auto .

HUMAN RESOURCE MANAGEMENT HRM-023 PAGE: 1


A8: USE OF PRIVATE MOTOR VEHICLE (PMV) FOR WORK PURPOSESDO YOU HAVE A VEHICLE YOU ARE PREPARED TO USE FOR WORK PURPOSES (ON RECEIPT OF MOTOR VEHICLE ALLOWANCE?)

IS VEHICLE COMPREHENSIVELY INSURED?

Yes No [If “No” skip remaining PMV questions] Yes No HAVE YOU EVER BEEN DISQUALIFIED FROM DRIVING?

Yes [If “Yes” please outline circumstances below] No DISQUALIFICATION CIRCUMSTANCES

.A9: PRIOR EMPLOYMENT WITH ROCKY BAYHAVE YOU EVER BEEN EMPLOYED BY ROCKY BAY PRIOR TO THIS APPLICATION? MOST RECENT PERIOD OF EMPLOYMENT

Yes No [If “No” skip remaining prior employment questions] From To REASON FOR LEAVING EMPLOYMENT AT ROCKY BAY

REASON FOR RETURNING TO EMPLOYMENT AT ROCKY BAY

.A10: LANGUAGE OR LEARNING ASSISTANCEWILL YOU REQUIRE ASSISTANCE WITH LEARNING, [I.E. READING, WRITING, WORKING WITH NUMBERS]

LEARNING ASSISTANCE REQUIRED

Yes [If “Yes” describe assistance required >> No .A11: TERTIARY EDUCATION HISTORYDO YOU HAVE ANY COMPLETE OR PARTIAL TERTIARY EDUCATION HISTORY?

Yes [List additional qualifications at the end of this form] No [If “No” skip the remainder of this section]NAME OF QUALIFICATION COMPLETE YEAR COMMENCED YEAR COMPLETED NAME OF INSTITUTION

Yes No

Yes No

Yes No

Yes No .A12: OTHER EDUCATION HISTORYDO YOU HAVE ANY OTHER EDUCATIONAL OR INDUSTRY QUALIFICATIONS OR SKILLS HISTORY?

Yes [List additional skills or qualifications at the end of this form] No [If “No” skip the remainder of this section]NAME OF QUALIFICATION OR SKILL COMPLETE YEAR COMMENCED YEAR COMPLETED NAME OF INSTITUTION

Yes No

Yes No

Yes No

Yes No



Section C – HealthIMPORTANT NOTE

Disclosure of a medical condition or restriction does not necessarily exclude an applicant from employment. As part of our selection process Rocky Bay reserves the right to get independent confirmation that candidates are able to perform the tasks associated with the role. We may ask candidates to undertake a function test for this purpose and, if we do, the cost of the examination will be met by Rocky Bay.Please tick YES or NO to every question. You should answer YES if you have ever suffered injury to the relevant area regardless how long ago it happened. If you answer YES please provide full details in the space provided

.C1: PERSONAL HEALTH HISTORYINFECTIOUS DISEASES: HAVE YOU HAD ANY OF THE FOLLOWING INFECTIOUS DISEASES? [CHECK BOXES AS APPROPRIATE]

German Measles Measles Chicken Pox

Hepatitis A Hepatitis B Hepatitis C .C2: PERSONAL HEALTH HISTORYIMMUNISATIONS:

Measles Date: Influenza Date: Hepatitis A and B Date:

Hepatitis C Date: Chicken Pox Date: MMR (Measles, Mumps, Rubella Date: .C3: PERSONAL HEALTH HISTORYQUESTION RESPONSE DETAILS [IF YOU CHECKED “YES”]

Do you have any disability, illness or injury that might affect your performance of the role applied for, or necessitate Rocky Bay modifying your work environment (i.e. ramp, etc)?

Yes No

Are you allergic to or otherwise react to any antibiotic, medicines, drugs, insect bites, food or anything else?

Yes No

Do you or have you had any medical or health related condition that may be affected as a result of being exposed to medications, detergents, cleaning solutions and pesticides (e.g. respiratory conditions such as asthma, dermatitis or eczema, allergenic reactions, etc)?

Yes No

Have you or are you receiving treatment for an injury, illness or side effect as a result of being exposed to chemical or toxic substances or use of personal protective equipment (e.g. gloves)?

Yes No

Have you ever lodged a Worker’s Compensation claim with an employer?

Yes No

.C4: GENERAL BACKGROUND INFORMATIONQUESTION RESPONSE DETAILS [IF YOU CHECKED “YES”]

Are you currently receiving medical treatment for any illness or condition?

Yes No

Are you currently taking any medications including inhalers? Yes No

Have you ever had an X-ray or scan of your neck and/or back? Yes No

Have you ever had a chest X-ray? If so, when and where? Yes No

Have you ever spent time in hospital as an in-patient? Yes No

Have you ever had an injury or disease resulting from work? Yes No

Have you recently required treatment from a chiropractor or Yes No



C4: GENERAL BACKGROUND INFORMATION

physiotherapist?

Are you able to wear personal protective equipment without irritation or experiencing problems of any kind? (eg gloves, safety boots, ear muffs/plugs, helmet or safety glasses)

Yes No

Over the last few years, have you lost time from work because of any illness and/or injury?

Yes No

Have you had exposure to any toxic substances or environmental hazards?

Yes No

Have you ever been a patient or worked in a health facility outside WA in the past 12 months? If yes, specify where.

Yes No

Do you suffer or have you ever suffered from repetitive strain injury?

Yes No

Are you currently pregnant? If so, what is your due date? Yes No

Have you been involved in Motor Vehicle Accident? If so, when?

Yes No

Do you have any physical disability? Yes No

Is there any history of serious illness or medical conditions in your immediate family?

Yes No

Have you lost or gained weight over the past year? If so, how much?

Yes No

…C5: MEDICAL CONDITION QUESTIONSHAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING CONDITIONS?

Defect in sight of either eye Yes No Sciatica, Back pain, back injury Yes No

Diabetes or predisposition to diabetes Yes No Skin problems eg Dermatitis, Eczema Yes No

Defect in hearing Yes No Sinus trouble Yes No

Vertigo (fear of heights) Yes No Earache or discharging ears Yes No

Claustrophobia Yes No Hernia/rupture Yes No

Irregular heartbeats, palpitations Yes No Rheumatic Fever Yes No

Heart trouble, angina, chest pain Yes No Hay Fever/Allergies of any kind Yes No

Shortness of breath Yes No Hepatitis/Jaundice Yes No

High blood pressure Yes No Stomach or duodenal ulcers Yes No

Wheezing/asthma Yes No Gall/kidney/bladder problems Yes No

Tuberculosis or Pleurisy Yes No Colour blindness Yes No

Depression Yes No Passing or vomiting blood Yes No

Anxiety, panic attacks, insomnia Yes No Goitre or thyroid problems Yes No

Mental illness Yes No Cancer or tumour of any kind Yes No

Swollen or painful joints Yes No Neck pain and/or injury Yes No

Broken or fractured bones, dislocations Yes No Fainting Spells, blackouts, loss of consciousness

Yes No

Rheumatics, arthritis Yes No Head injury of concussion Yes No

Persistent headaches or migraines Yes No Deep Vein Thrombosis Yes No

Epilepsy/Fits Yes No Other joint injuries or conditions Yes No



C5: MEDICAL CONDITION QUESTIONS

Ankle or Knee trouble or injury Yes No Foot trouble or injury Yes No

Wrist/elbow trouble or injury Yes No Severe injury or operation Yes No

Tendency to bruise or bleed excessively Yes No Spinal problems including whiplash Yes No

Shoulder pain and/or injury Yes No Yes No ENTER ANY COMMENTS FOR ANY CONDITIONS EXPERIENCED ABOVE

.C6: MANUAL HANDLINGDO YOU HAVE DIFFICULTY WITH ANY OF THE FOLLOWING?

Bending down, kneeling, crouching Yes No Working at heights Yes No

Lifting heavy objects Yes No Chronic fatigue Yes No

Walking on uneven ground or surfaces Yes No Standing for extended periods of time Yes No

Lowering, pushing or pulling heavy objects Yes No Moving, holding or restraining any object Yes No

Going up and down stairs or ladders Yes No Crouching/bending/kneeling Yes No

Sitting for extended periods of time Yes No Carrying heavy objects Yes No

Do you suffer from any medical or health related conditions that may be affected by physical or strenuous work (e.g. tasks such as those stated above)?

Yes No

Have you ever been treated for an injury as a result of or while attempting to perform any of the above stated tasks?

Yes No

IF YOU CHECKED “YES” TO EITHER OF THE LAST TWO QUESTIONS, PROVIDE FURTHER DETAILS BELOW

Dates:

Nature of Injury / Medical Condition

What occurred

Treatment Detail

Length of Time Off Work DETAILS OF ANY OTHER PAST OR PRESENT CONDITION NOT PREVIOUSLY MENTIONED WHICH MAY IMPACT ON YOUR ABILITY TO SAFELY PERFORM THE DUTIES THAT WILL BE REQUIRED OF YOU IN THE POSITION YOU ARE APPLYING FOR?

…C7: HEALTH HABITS AND PERSONAL SAFETYQUESTION RESPONSE DETAILS [IF YOU CHECKED “YES”]

Do you smoke or have you ever smoked? Yes No If “Yes”, how many per day?

Do you exercise regularly? Yes No If “Yes”, how often per week and type

Do you take illicit drugs of any kind? Yes No If “Yes”, provide details

Do you drink alcohol? Yes No If “Yes”, average number of standard drinks per week:



Section D – AvailabilityIMPORTANT NOTE

Complete this section ONLY if you are applying for a position as a Disability Support Worker, Nurse, Monitoring & Support Officer or other shift position

…D1: SHIFT AVAILABILITYWHAT SHIFTS ARE YOU PREPARED TO WORK? RESPONSE

Work night duty Regularly Occasionally Rarely Not at all Not applicable

Work shifts Regularly Occasionally Rarely Not at all Not applicable

Work flexible hours Regularly Occasionally Rarely Not at all Not applicable

Work on public holidays Regularly Occasionally Rarely Not at all Not applicable …D2: WORKING HOURSPLEASE INDICATE BY INSERTING AN “X” IN EACH SQUARE BELOW, CORRESPONDING TO THE HOURS YOU WOULD NORMALLY BE ABLE TO WORK ON A GIVEN WEEK.

Time From

1 a

m

2 am

3 am

4 am

5 am

6 am

7 am

8 am

9 am

10 a

m

11 a

m

12 n

oon

1 pm

2 pm

3 pm

4 pm

5 pm

6 pm

7 pm

8 pm

9 pm

10 p

m

11 p

m

12 m

idni

ght

Day

Example

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Public Holidays



Section E – Applicant DeclarationIMPORTANT NOTE

PLEASE read the following declaration carefully before submitting this application. .DECLARATION:PLEASE READ AND COMPLETE THE FOLLOWING DECLARATION

I [Type your name here] acknowledge that under the terms of Section 79 of the “Workers’ Compensation and Injury Management Act 1981”, should a worker, at the time of seeking or entering employment, wilfully and falsely represent himself/herself as not having previously suffered from an injury and subsequently claims compensation for that injury, the insurance company may refuse to award compensation which would otherwise be payable.

Under the Privacy Amendment (Private Sector) Act 2000, I consent to Rocky Bay retaining the information stated herein on file for possible future employment purposes.

I consent to any reference checks which may be necessary to support this application. I understand that Rocky Bay reserves the right to independently verify my Visa, drivers licence (including State Traffic Certificate with certified copy of traffic infringement and demerit points), Working with Children and Police Clearance details, and to access details of any convictions that may be ‘spent’ (removed from a person’s public viewable policy record). I consent to Rocky Bay doing so.

I certify that my answer to each of the above questions is true and that this information is correct. I understand that any misrepresentation of facts in this application could be cause for instant termination if I am employed by Rocky Bay.IF HANDING IN THIS APPLICATION FOR EMPLOYMENT FORM IN A PAPER OR OTHER PHYSICAL FORM, SIGN HERE TO INDICATE THAT YOU HAVE READ THIS FORM, FILLED IT IN COMPLETELY AND THAT YOU CERTIFY THE ABOVE.

IF SUBMITTING THIS APPLICATION FOR EMPLOYMENT FORM ELECTRONICALLY, PLACE AN ‘X’ IN THE BOX BELOW TO INDICATE THAT YOU HAVE READ THIS FORM AND FILLED IT IN COMPLETELY AND THAT YOU CERTIFY THE ABOVE.

OR

DATE DATE

E1: RECRUITMENT SOURCEWHERE DID YOU SEE THIS VACANCY ADVERTISED?

Rocky Bay website SEEK website West Australian Newspaper

Word of Mouth Other Source (specify ) Other Newspaper (specify ).E2: SUBMISSION INSTRUCTIONSYOUR APPLICATION SHOULD INCLUDE:

This form (completed) Your resume (providing information about your employment history, qualifications/skills and referees) A document matching your skills/experience against the selection criteria for the roleSUBMIT YOUR APPLICATION TO:

Email: [email protected]

Fax: (08) 9383 1230

Post: Human Resources Team, PO Box 53, Mosman Park, WA 6912

Personal Delivery: Human Resources Team, 60 McCabe Street, Mosman Park, Western Australia


application for employment - web viewword of mouth . other source (specify ) other newspaper...

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