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Portfolio Formulation Forms La Trobe University University of South Australia Terri Scheer Insurance Brokers BDO Chartered Accountants & Advisers Institute of Public Administration Australia Department of Treasury and Finance Oakhill College Department of the Premier and Cabinet Donnellys Insurance Brokers Advanced Manufacturing CRC


La Trobe University Australia Application form and process for outgoing exchange students

Personal Details Family name Given name(s) Date of birth

Student number /

/

Title

Country of birth

(Mrs, Miss, Ms, Mr etc)

Sex: Female

Citizenship

Address for Correspondence Number and street Suburb and country

Postcode

Phone (home)

Facsimile

Phone (mobile)

Email

Emergency Contact (in Australia) Name

Relationship to applicant

Phone (home)

Phone (work)

Phone (mobile) Current Enrolment Degree enrolled in Year of course

Expected year of completion

La Trobe campus Application Deadlines Application deadlines vary for each institution and can be anywhere between: Applying for LTU Semester 1:

1 July – 1 November of the previous year

Applying for LTU Semester 2:

1 February – 1 May of the same year

For each institution’s specific deadline visit our website www.latrobe.edu.au/international/exchange/partners Exchange Program Host Institution I wish to study overseas for: one semester Semester commencing: La Trobe University semester 1 La Trobe University semester 2 Year commencing

two semesters (usually January start) (usually September start)

Male


La Trobe University Australia Application form and process for outgoing exchange students

Study Plan List more subjects than you require at the host institution (8–10 subjects per semester) * For subject approvals you must see your Course Advisers – please see list on our website www.latrobe.edu.au/exchange/local Host institution subject code

Host institution subject name

Host institution credit points

LTU equivalent subject code

LTU equivalent subject name

Subject approval/ credit will be granted Signature of LTU Adviser


La Trobe University Australia Application form and process for outgoing exchange students

Internal Use Only The Faculty of (faculty name): has examined (student name): study plan for a student exchange program to (host institution): (host country):

from (month & year):

to (month & year):

and agrees to the following credit for his/her proposed study plan. The student must successfully complete a full-time load (number of host institution credit points): to be eligible for (number of LTU credit points):

credit points at LTU.

NB: If the student needs to vary any of the approved study plan he/she must contact the Faculty Adviser in writing to seek approval for any changes.

Faculty Adviser name Position Signature

Date

/

/

Date

/

/

Contact details Head of School/Dean of Faculty name Signature

If there are any units in the attached study plan which are compulsory for this student please list them below: Host institution discipline/subject

LTU credit point value


La Trobe University Australia Application form and process for outgoing exchange students

Please attach the following information 1. Official original transcript of results (can be purchased at Student Centre, Bundoora campus) 2. References: please attach two (2) references (one personal and one academic) that include contact details of your referees 3. Autobiographical essay up to 700 words. Consider including the following: • reasons for wishing to study abroad; • reasons for choosing the institution you have nominated; • how you think you will benefit from the exchange program, both personally and academically; • why you would be an outstanding ambassador for Australia, in general, and La Trobe in particular. 4. Source of funding Student personal funds (if family funds, give full name and address of the person responsible) – $A

Funds from scholarships, exchange grant, loan fund, etc (give source and attach an official copy of your award letter) – $A

Funds from other sources (from a sponsor (a person outside your family), give sponsors full name and address) – $A

To apply Submit your completed application*to: Study Abroad & Student Exchange Adviser in the International Programs Office, Tower 7, Chisholm, Bundoora campus. Make two copies of your application (keep one for your files and

Bendigo Campus Student Exchange Adviser, Julie Gibbons International Office submit one with your original to the Adviser)

* A complete application includes all information required on the LTU application form, PLUS the host institution application form (where applicable). Seek advice from the Study Abroad and Student Exchange Adviser to see what application forms you need.

Declaration and agreement • I understand that acceptance into the La Trobe Exchange program is subject to the acceptance of my application by the proposed host institution • I understand that I am required to study full time for the term of my exchange and that I will maintain a full time enrolment at La Trobe for the term of my exchange • I understand that if I withdraw from the exchange program without the authorization of the Committee for External Programs, I will be liable to repay all or part of any grant paid to me, as determined by the Committee for External Programs • I understand and agree that I must provide a written report to the International Programs Office at the completion of my exchange program

• I understand and agree to attend the compulsory pre-departure program • I understand that if I vary my enrolment I must seek approval for these changes. If I do not get approval I understand I may not receive credit for my studies overseas • I understand that it is my responsibility to maintain a valid full time enrolment and to ensure a proxy is arranged if necessary • I understand that La Trobe will withdraw my application should I fail to fulfil the conditions outlined • I have submitted a complete application • I certify that the information I have provided in this application is accurate and true in every detail

Student Signature

Date

/

/

IPO Approved

Date

/

/

Official University Stamp (IPO)


Application For Admission SCHOOL OF MARKETING GRADUATE CERTIFICATE IN MARKETING GRADUATE DIPLOMA IN MARKETING MASTER OF MARKETING

IDENTITY NUMBER (OFFICE Due date for applications: 14 November for late January start

USE ONLY)

PROGRAM DETAILS I apply for admission to the program leading to the award: Part-time Full-time On-campus Have you applied for this program previously: Yes Commencement Term and Year:

14 May for July start

GRADUATE CERTIFICATE IN MARKETING (WINE MARKETING) GRADUATE DIPLOMA IN MARKETING (WINE MARKETING) MASTER OF MARKETING (WINE MARKETING)

PERSONAL DETAILS (TO BE Title (eg Mr, Ms, Dr etc): Family name Any previous family name Home address Suburb or Town Postcode Mailing address Suburb or Town Postcode Telephone Home Mobile Number Email

Term 1, 20

On-line No

Term 3, 20

COMPLETED IN BLOCK OR UPPERCASE LETTERS)

Date of birth:

/ / Given names

Sex: Male

Female

State Country State Country Telephone Business Facsimile

STATISTICAL DATA Citizenship and residence status during this semester (tick one of the five boxes) 1.

Australian Citizen (including Australian Citizens with Dual citizenship)

2.

New Zealand Citizen

3.

Permanent resident status (excluding New Zealand citizenship) – SEE QUESTIONS BELOW

4.

Temporary entry permit/visa or you are a diplomat or a dependent of a diplomat (except New Zealand) and reside in Australia during the semester

5.

Reside overseas during the semester and are NOT an Australian or New Zealand citizen and you do NOT have permanent resident status

Only answer the questions below if you ticked box 3 in the questions above 0. You were granted permanent resident status before 1996 or commenced your current course before 1996 As of today you have permanent resident status but have not met the residence requirements for Australian citizenship, OR, have met the residence requirements within the previous 12 months AND 1.

You are residing in Australia for the semester, or residing outside Australia for the semester as a requirement of the course, OR

2.

You are residing outside Australia for the semester but not because of a requirement of the course

3.

As at today you have had permanent resident status for more than 12 months after the date on which the residence requirements for Australian citizenship status were met.

Day, month and year permanent residence was granted: In what country were you born?

Australia

/

/

Other

If you answered ‘Other’ please provide the name of the country In what year did you first arrive in Australia?

Prior education – important Selection for admission to most programs is based, wholly or in part, on your secondary and tertiary results. It is vital that you submit, with your application form, a statement of your academic record issued by each of the education institutions you have attended, showing all courses attempted and results achieved. Tertiary Studies (please attach a separate page if this is insufficient space) Award

Institution

Major field of study

Completed Yes/No

Start Year

End Year


Prior education – important (continued) Preclusion (please attach a separate page if this is insufficient space) Have you ever been precluded from study at this University or any other higher education institutions? Yes

No

If Yes, please give details:

Membership of professional societies (state grade)

Relevant Employment Experience (please attach a separate page if this is insufficient space) Employer/Organisation

Position

Nature of Experience

Period From/To

Special circumstances affecting selection decisions Please give details of any circumstances affecting previous study that you would like brought to the attention of the selection panel (such as serious illness, involvement in student or community organisations, employment situation, etc). If there is not enough room then attach a separate sheet giving details.

International Applicants Only English Proficiency Proficiency in English is essential for successful study at an Australian university. All applicants must demonstrate an acceptable level of English proficiency to gain admission to the University. Please indicate below your current proficiency and attach certified copies of your most recent test result. No First language is English: Yes English was the language of instruction in tertiary studies completed: Yes No IELTS overall band score: Date obtained / / Financial Support (please indicate your source of financial support) I am fully sponsored by my Home Government (attach documentation) I am fully sponsored by my Employer (attach documentation) I am a private student sponsored by myself/my family Name and address of person or organisation paying fee (for invoice purposes) Name Address Suburb or Town State Postcode Country Telephone Facsimile (include country & area code) (include country & area code) Email

Referees Reports You will need to arrange for the submission of two Referee Reports; • EITHER one Business Referee Report and one Academic Referee Report; • OR two Business Referee Reports. Please photocopy the appropriate forms. Complete the top sections of the enclosed forms and pass them on to your referees who should return their reports directly and in confidence to the School of Marketing. The completed forms need to be returned before the due date. POST TO: School of Marketing City West Campus GPO Box 2471 Adelaide SA 5001 CONTACT: Telephone (08) 8302 0723 Facsimile (08) 8302 0442 Email postgrad.marketing@unisa.edu.au CRICOS Provider Number 00121B

Declaration I declare that the information given in this application is true and complete. I acknowledge that submission of incorrect information relating to my application may result in the cancellation by the School of Marketing, or the withdrawal by the University of South Australia, of any place that may be offered and that this withdrawal may take place at any stage during the program. I understand that it its my responsibility to attach to this application complete official academic transcripts of all my post-secondary programs. I understand that it’s my responsibility to ensure that referees send their confidential reports directly to the School of marketing by the due date.

Signature

Date


Business Referee Report

CONFIDENTIAL

SCHOOL OF MARKETING GRADUATE CERTIFICATE IN MARKETING GRADUATE DIPLOMA IN MARKETING MASTER OF MARKETING

GRADUATE CERTIFICATE IN MARKETING (WINE MARKETING) GRADUATE DIPLOMA IN MARKETING (WINE MARKETING) MASTER OF MARKETING (WINE MARKETING)

COPY THIS FORM AND SEND IT TO YOUR REFEREE TO BE COMPLETED To be completed by Applicant

Thank you for your co-operation.

Applicant’s name Address

Date

Telephone

The program for which application is being made

To be completed by Referee Referee’s name

Position

Company Address

Telephone

Facsimile

How many years have you known the Applicant, and in what connection?

Referee’s opinion on the ability of the Applicant to handle the workload as described in the program documentation:

Referee’s opinion on the value of the relevant program to the Applicant:

Would you be willing to provide additional details by phone or fax if necessary?

Signature

Yes

Date

No

Please complete and return this form directly to: School of Marketing GPO Box 2471 Adelaide SA 5001 Facsimile (08) 8302 0442


Academic Referee Report

CONFIDENTIAL

SCHOOL OF MARKETING GRADUATE CERTIFICATE IN MARKETING GRADUATE DIPLOMA IN MARKETING MASTER OF MARKETING

GRADUATE CERTIFICATE IN MARKETING (WINE MARKETING) GRADUATE DIPLOMA IN MARKETING (WINE MARKETING) MASTER OF MARKETING (WINE MARKETING)

COPY THIS FORM AND SEND IT TO YOUR REFEREE TO BE COMPLETED To be completed by Applicant

Thank you for your co-operation.

Applicant’s name Address

Date

Telephone

The program for which application is being made

To be completed by Referee Referee’s name

Position

Institution Address

Telephone

Facsimile

How many years have you known the Applicant, and in what connection?

Program that the Applicant was undertaking

Years

Referee’s opinion on the ability of the Applicant to handle the workload as described in the program documentation:

Referee’s opinion on the Applicant’s recent academic performance:

Please complete and return this form directly to: School of Marketing GPO Box 2471 Adelaide SA 5001 Facsimile (08) 8302 0442

Would you be willing to provide additional details by phone or fax if necessary?

Signature

Yes

Date

No


Landlord Preferred Policy queensland & nth new south wales terri scheer® insurance brokers pty ltd

Many standard insurance policies do not cover the risks often associated with rental properties such as malicious damage or

ABN 76 070 874 798

PO Box 1775 Sunnybank Hills QLD 4109

Policy however, is specifically designed for landlords and provides

QLD SA / NT / TAS WA VIC / ACT NSW

comprehensive cover for your property including:

tsibqld@terrischeer.com.au www.terrischeer.com.au

theft by tenants and their guests. Terri Scheer’s Landlord Preferred

Loss of rent

Loss or damage – Contents

Our policy will pay for loss of rent caused by:

Our policy covers general household contents including curtains, blinds, light fittings and even furniture left for the tenant’s use.

Premises left untenantable due to malicious damage to the building and contents Up to 52 weeks rent Absconding tenant* Up to 6 weeks rent Defaulting payments resulting in eviction of your tenant by Court Order* Up to 15 weeks rent Prevention of access Up to 52 weeks rent Failure to give Vacant Possession Up to 28 weeks rent

These items are covered against loss resulting from:

Accidental loss or damage Malicious damage by all persons, including tenants Theft, riot and civil commotion Fire, explosions, lighting and earthquakes Breakages of fixed glass

Death of Tenant (under a sole tenancy) Up to 15 weeks rent

Storm and rainwater

Tenant Hardship (When Court awards a tenant a

Impact damage, leakage of oil

release from lease obligation due to hardship)

Up to 4 weeks Legal expenses Up to $5,000 Legal Costs Up to $500 We’ll make sure you still have income from your property to meet your expenses. (note – weekly rent is subject to a maximum of $1,000 unless previously agreed). * Landlords are not required to contribute any portion of the bond monies to a loss of rent claim.

Water damage (excluding flood) Fusion – limit $2,000 We’ll repair or replace your damaged items under the Building or Contents Section of the Policy to a maximum combined amount of $45,000.

Legal liability We’ll cover your legal liability as a landlord for an occurrence which causes: Death or bodily injury to other people Damage to other people’s property

Loss or damage – Building (limited cover) Our policy covers your property against loss or damage resulting from: Malicious damage to the structure of the building by tenants, their family and/or invitees Theft by tenants, their family and/or invitees

(07) 3216 9555 (08) 8363 3800 (08) 9471 1511 (03) 9576 2533 (02) 9413 9700

Limit of indemnity $20,000,000

Excess Accidental loss or Damage: $500 per event Malicious Damage: $500 per claim Earthquake: $200 Other claims: $100 Loss of rent: only* $180

Disclaimer: This is a brief outline of the main features of the Landlord’s Preferred Policy. For full details of terms, conditions, limits and exclusions refer to the policy document. Please Note: If rent is in arrears now, or has been in the previous two months, contact Terri Scheer Insurance Brokers before placing cover as restrictions may apply.


Landlord Preferred Policy queensland & nth new south wales

Important Notice Important information about the policy The printed policy explains the insurance you are arranging in detail. There are some important provisions in the policy which you should understand, otherwise there may be disappointment when you wish to make a claim. The cover provided differs from the standard cover required by the Insurance Contracts Act, 1984. For example, you should understand that the policy does not cover flood damage to Buildings or Contents. You should also know that the excess applies to most claims. An excess is an amount which you must pay before a claim can be made under the policy.

Protect your investment today... Simply complete and return this form to your property manager today. Or, if you prefer, you can call Terri Scheer Insurance Brokers and your property will be covered immediately. For a complete insurance package for your property, ask your agent about Terri Scheer’s Building Insurance. You’ll be amazed how it compares with your current policy. Yes as the landlord, I would like to protect my property and property contents, with Terri Scheer’s Landlord Preferred Policy. Name Postal Address

Mobile Please cover the following property(s). 1. 2.

Important Notice – Your duty of disclosure ‘You’, ‘your’ means all persons named in the policy as the insured and ‘we’, ‘our’, ‘us’ means the insurers through their agent, QBE Mercantile Mutual Limited. Your duty of disclosure The law requires you to tell us everything you know (or could reasonably be expected to know in the circumstances) which is relevant to our decision to insure you and the terms on which we insure you. This duty applies before you enter into a contract with us, that is, before we accept your proposal and also each time before you alter or renew the Policy. Each person named as the insured has the same duty.

Daytime phone

My Real Estate Agent is Property Manager

Please answer the following questions concerning your insurance history. 1.

Has any insurer ever declined to insure you or declined to renew your policy or asked that you agree to special terms or conditions? Yes

2.

No

Have you during the past three years made three or more claims under a Landlord’s Protection policy or made a claim for more than $2,000? Yes

No

If you have answered Yes to either question above please provide details:

Penalty for non-disclosure If you do not tell us everything necessary, we may; reduce or refuse to pay a claim, or cancel your Policy. If you act dishonestly, we may invalidate the Policy from its beginning and not be bound by it.

Landlord’s Signature

Date

/

/

You don’t need to tell us anything which: reduces the risk, is common knowledge, we already know, or ought to know in the ordinary course of our business, or we indicate we do not want to know. If you are not sure that something is relevant, it is best to disclose it anyway.

This policy is underwritten by the Insurers set out below in the following proportions: 50% – QBE Insurance (Australia) Limited ABN 78 003 191 035 of 82 Pitt Street, Sydney 50% – Mercantile Mutual Insurance (Australia) Limited ABN 35 000 456 799 of 347 Kent Street, Sydney This means each insurer is only responsible for its 50% share. In arranging and effecting this policy, QBE Mercantile Mutual Limited ABN 28 087 142 569 will be acting under authority given to it by the contents Insurers. It will be acting as agent of the contents Insurers not as your agent. MANAGEMENT FEE: Your agent is paid a management fee of approximately $1.25 per month by the Insurance brokers for arranging this insurance on your behalf. This insurance is only available if your property is managed by a licensed Real Estate Agent.


business

Chartered Accountants & Advisers

Financial Management Software (FMS) This survey will allow BDO to gain a better appreciation of the FMS utilised by Australian wineries and to share this information with wine businesses throughout Australia. Thank you for your time to complete this survey. Please return completed by faxing it to BDO (SA) on (08) 8232 0902 and enter the draw to win a $200 MYER voucher and a BDO Optimist Financial Health Check valued at $700. If you wish to enter the draw, please provide your contact details at the end of this form to enable us to contact you.

Q Q

Q

1. What size is your winery? (please tick) Micro Small Medium Large

Tonnes

‘000 Cases

<20 20 – 250 250 – 1,000 > 1,000

<1.5 1.5 – 17.5 17.5 – 75 > 75

7. BDO and its software partners are currently developing FMS solutions for small to medium wineries that will provide better data reporting functionality. How interested would you be in upgrading your software? Not at all interested Not very interested Not sure Somewhat interested Extremely interested

2. Which software do you currently use for financial management? MYOB Quickbooks Attache Pro-time Wine File Ezysystems TSM Other (please specify)

Q Q Q Q

Q Q

8. How much would you be prepared to budget for FMS? $0 – $1,000 $1,000 – $3,000 $5,000 – $10,000 $10,000 – $20,000 $20,000 +

3. Do you also use winery management software to handle the wine production process? Yes

survey

wine

9. BDO and our software partner are seeking a pilot site in which to conduct a free installation and test new FMS software. How interested would you be in becoming a pilot site? Not at all interested Not very interested Not sure Somewhat interested Extremely interested

No

If yes, please specify the software provider:

4. Who operates your FMS? Winemaker Owner Accountant (external) Accountant (internal)

If you have any comments or suggestions, please provide them in the space below:

5. What version (if any) of Microsoft Excel do you use? Excel 03 Excel XP Excel 2000 Pre Excel 2000 Do not use Microsoft Excel

Your Details:

6. FMS available for wineries differ in their functionality. Does your FMS report the following information for a single specific product? a: Vineyard costs (including Lease / Depreciation) per hectare? b: Vineyard costs (including Lease / Depreciation) per tonne? c: Crushing costs per tonne? d: Winemaking costs (from crush to bottle) per litre in process? e: New barrel cost per litre in barrel? f: Used barrel cost per litre in barrel? g: Bottling and packaging cost per case? h: An accurate finished goods cost per case? i: An accurate gross profit margin for each sale? j: An analysis of gross profit margins for each sales distribution channel? k: Net WET/GST (after rebates) owing for each sale?

Yes

No

Unsure

Name: TITLE

FIRSTNAME

SURNAME

Company: Postal Address: STATE

Phone: (

)

POSTCODE

Mobile:

Email: When completed, please fax to: BDO, Chartered Accountants & Advisers on (08) 8232 0902 before Friday 20th February 2004. The winner will be contacted direct and their name posted on www.virtualwinery.com.au.

Thank you for your participation. Good luck in the draw! ANY DETAILS PROVIDED BY YOU IN THE COURSE OF THIS SURVEY WILL BE TREATED IN ACCORDANCE WITH THE NATIONAL PRIVACY ACT. FOR FULL DETAILS, PLEASE VISIT US ON WWW.BDO.COM.AU.


www.sa.ipaa.org.au

IPAA Membership is open to… any person interested in or concerned with the practice, study or teaching of public administration. Membership provides access to the publications, functions and services of the Institute at a reduced cost. Concessional membership applies to retirees, fulltime students, those earning less than $35,000 per annum or are aged 34 and under. Corporate Membership provides cost reductions for private sector organisations wishing to take advantage of this class of membership.

MEMBERSHIP FEES FOR 2003–2004 FINANCIAL YEAR (inclusive of GST) Full Membership: Concessional Membership: Corporate Membership:

$120 or $4.70 per fortnight (includes quarterly Australian Journal of Public Administration) $60 or $2.35 per fortnight (includes quarterly Australian Journal of Public Administration) $300 available to private sector organisations only

Application for Membership

ABN: 73 759 280 961

Surname:

Given Names:

Preferred First Name:

Date of Birth:

Organisation: Salary Band:

Salutation:

/

/

Position: < $35,000

$35,001 – $50,000 $70,001 – $80,000

$50,001 – $60,000 $80,001 – $90,000

$60,001 – 70,000 > $90,001

Work Address: DX Number:

Mobile:

Work Phone:

Work Fax:

Preferred Email Address:

Newsletter: Electronic/Post

Address for Correspondence (if different from work address): Home Address: Home Phone:

Home Fax:

Issues I would like IPAA to address:

Method of Payment Payroll Deduction form completed and forwarded to pay officer $2.35 $4.70 (per fortnight) Optional: Canberra Bulletin of Public Administration (CBPA) – $68.00 (GST inclusive) Full membership

Concessional

Corporate

Cheque enclosed for: Membership only Membership & CBPA

$120.00 $188.00

$60.00 $128.00

$300.00 $368.00

Please send an invoice for: Membership only Membership & CBPA

$120.00 $188.00

$60.00 $128.00

$300.00 $368.00

Please debit my: Membership only Membership & CBPA

Mastercard $120.00 $188.00

Visa

Bankcard $60.00 $128.00

Institute of Public

Amex $300.00 $368.00

Administration Australia South Australian Division Inc GPO Box 13 Adelaide SA 5001

Card No:

Expiry Date:

/

/

DX 449 Adelaide Telephone (08) 8212 7555 Facsimile (08) 8212 0155

Card Holder’s Name:

Signature:

A D V A N C I N G

T H E

P U B L I C

enquiries@sa.ipaa.org.au

S E C T O R


S4

This incident report is required by Integrated Security on all security incidents within the DTF to improve the departmentâ&#x20AC;&#x2122;s safety and security.

Security incident report u Did yo a s s e n it w y securit t? n e incid

If you have witnessed a security incident, please fill out this report.

1

Indicate time of incident

Any questions completing this form? Call:

2

Record your details

Integrated Security Telephone 08 â&#x20AC;&#x201C; 8226 3605

3

Please provide a clear description of the incident, including any assets that may have been affected

4

Send the completed form to: Integrated Security Corporate Services

This form needs to be signed by yourself and your Branch Manager

Time of incident

1

Date

Time

____/____/_________

_____ : _____

am pm

Reported by

2

Surname

First name

Branch/section

Incident report Please describe the incident

3

In the incident, DTF items/assets were: damaged lost not affected stolen

List of affected items

Action taken

Was the incident reported to Manager, Integrated Security? Was the incident reported to the Police?

YES YES

NO NO

Police report number

Complete asset transfer form (#) if stolen, lost or damaged beyond repair

Signatures Name

4

Signature

Date

Employee/ witness

____/____/_________

Branch Manager

____/____/_________

Reset Form

Save Form

Print Form

Only users with a minimum of Acrobat Reader 7 are able to SAVE this form.


S3

This form is used by DTF Corporate Services to keep an up-to-date record of all access permits issued for entry into State Administration Centre, Victoria Square, Adelaide.

Security access request to State Administration Centre Need access e to Stat ? n i Adm

This form needs to be filled out before security access can be granted. Follow these steps

1

Please provide cardholder details

2

Provide details of person making this request and specify the required action and card type

3

Please specify requested door access and time

4

After both cardholder and manager have signed the form, please send it to Corporate Services, Purchasing and Facilities, DTF

Any questions completing this form? Call: Integrated Security Telephone 08 – 8226 3605

Send the completed form to: Purchasing and Facilities Corporate Services

Cardholder’s details Surname

First name

Position title

Branch/Section

1

Requester

2

Surname

First name

Required action New card Reason for replacement

Alteration

Replacement Card number

Card type Permanent

Temporary

Valid until ______/______/__________

Cardholder agreement (to be completed upon receipt of card) I hereby agree that;

3

I shall not allow my card, or pin number, to be utilised by any unauthorised person.

If I become aware of any unauthorised use, or the misplacement, of my card or pin number, I will immediately report this to the Manager, Integrated Security.

Cardholder’s signature

Date ____/____/_________

> PAGE

I

II


Security access request to State Administration Centre

S3

continued

Access privileges Door Access

BH * 24/7 Authorised Person’s Name

4 Revenue SA – Grnd Revenue SA – Lvl 1 Revenue SA – Lvl 2 Corp Serv – Lvl 3 SuperSA – Grnd SuperSA – Mezz SuperSA – Lvl 4 SAFA/SAICORP – Lvl 5 GAR – Lvl 6 Finance – Lvl 7 UT – Lvl 8 Deputy Premier – Lvl 8 PGE/Policy Analysis – Lvl 9 DPC – Lvl 11 Nth Premier’s Office – Lvl 11 West DPC – Lvl 11 Sth OPE Lvl 12 DPC – Lvl 13 DPC Lvl 14 Premier’s Office – Lvl 15 DPC – Lvl 16 DPC, CEO – Lvl 16 *

Authorised Person’s Signature

Date

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

NAME

SIGNATURE

____/____/_________

Business hours are 7am–7pm, Mon–Fri

Security use only Cardholder’s name

Card number

Door access

Logged by

Card returned

Date registered

PAGE

Save Form

Access privileges cancelled

Return reason

____/____/_________

Reset Form

PIN number

Print Form

I

II Only users with a minimum of Acrobat Reader 7 are able to SAVE this form.


S2

This form is used by DTF Corporate Services to keep an up-to-date record of all Frequent Visitor Passes issued for entry into State Administration Centre, Victoria Square, Adelaide.

Request for

Frequent visitor access to State Administration Centre Need to access ? DTF

This form needs to be filled out before security access can be granted. Follow these steps

1

Please provide visitor details

2

Please provide details of the DTF staff member who will be responsible for this visitor

3

Please specify access reason and period

4

This form needs to be authorised by the Branch Manager and then forwarded to DTF Corporate Services, Integrated Security

Any questions completing this form? Call: Integrated Security Telephone 08 – 8226 3605

Send the completed form to: Integrated Security Corporate Services

Visitor*

1

Surname

First name

Position title

Company/Department

*

Branch/Section

NOTE: frequent visitor passes are NOT transferable. In certain circumstances Security staff may request to verify identification.

Person at DTF responsible for visitor*

2

Surname

First name

Branch/Section

Contact telephone number

*

NOTE: The responsible person needs to ensure that dates are valid on the Visitor Pass. If dates are not valid, a day pass will be issued.

Visitor access details Reason for access

3

Contractor Other Government Agency Supplier

Start date ______/______/__________ End date (Ministerial offices – 6 months ) ______/______/__________

NOTE: Visitor are passes onic r t c le not e access cards.

Branch Manager’s authorisation I approve the security access request as stated above.

4

Branch Manager’s signature

Date ____/____/_________

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S1

This form is used to keep an up-to-date record of all access permits issued for entry into Statewide House, 99 Gawler Place, Adelaide.

Security access request to Statewide House Need to access e u n Reve SA?

This form needs to be filled out before security access can be granted. Follow these steps

1

Provide details of person making this request and specify the required action and card type

2

Please provide cardholder details

3

Please specify requested door and alarm access

4 – 5 After both cardholder and manager have signed the form, please send it to Corporate Services, Purchasing and Facilities, DTF

Any questions completing this form? Call: Senior Advisory Services Officer Property Revenue Services Telephone 08 – 8207 2116

Send the completed form to: RevenueSA Property Revenue Services Telephone 08 – 8207 2116

Cardholder’s details

1

Surname

First name

Branch/Section

Position title

Requester Surname

First name

2 Required action New card

Alteration Reason for alteration

Original card number

Card type Permanent

Temporary

Valid until

______/______/__________

Access privileges

3

Door access 1.1.1

Main doors

Time frame* Business Hours 1.1.2

Time frame* Business Hours *

Branch Manager’s signature

Date ____/____/_________

24/7

All doors

Date ____/____/_________

24/7

Main doors

Time frame* Business Hours 1.1.3

Branch Manager’s signature

Branch Manager’s signature

Date ____/____/_________

24/7

Business hours are 7am–7pm, Mon–Fri

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S1

Security access request to Statewide House continued

Access privileges (continued) Door access

3

1.1.4

Computer room only

Time frame* Business Hours 1.1.8

*

____/____/_________

24/7

Level 6 main doors

Time frame* Business Hours

Date

Branch Manager’s signature

Date

Branch Manager’s signature

____/____/_________

24/7

Business hours are 7am–7pm, Mon–Fri

Alarm access 1.1.1

No access

Date

Branch Manager’s signature

____/____/_________ 1.1.30

All ESL areas

Date

Branch Manager’s signature

____/____/_________ 1.1.31

Manager

Date

Branch Manager’s signature

____/____/_________ 1.1.32

Staff

Date

Branch Manager’s signature

____/____/_________ 1.1.33

Computer room only

Date

Branch Manager’s signature

____/____/_________

Cardholder agreement

4

I hereby agree that; •

I shall not allow my card, or pin number, to be utilised by any unauthorised person.

If I become aware of any unauthorised use, or the misplacement, of my card or pin number, I will diligently inform the security supervisor.

Cardholder’s signature

Date ____/____/_________

Manager’s authorisation Approval must be given by appropriate manager prior to access being granted.

5

I approve the security access request as stated above. Branch Manager’s signature

Date ____/____/_________

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S1

Security access request to Statewide House continued

Security use only Logged by

Cardholderâ&#x20AC;&#x2122;s name

Card number

PIN number

Date registered ____/____/_________

Door access .

.

Card returned

Alarm access .

Return reason

.

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OH4

This form is used by DTF personnel to assess keyboard workstations to report and attend to any problems identified in the equipment, furniture, layout or system.

Keyboard workstation assessment checklist Time to he check t ics? m o ergon Please take these four steps to conduct the assessment.

1

Provide name of keyboard user.

2

Please use this checklist together with the illustration on page 3 to go through all workstation areas to identify any ergonomic problems.

Any questions? Call: OHS&W Services, Corporate Services Telephone 08 – 8226 3520

Send the completed form to: 3

List any problems and suggestions here.

4

Sign and return the completed form to the Senior Consultant at OHS&W Services.

OHS&W Services, Corporate Services Level 3, State Administration Centre 200 Victoria Square Adelaide SA 5000

Keyboard user Surname

First name

1

NOTE: To help with the assessment, please refer to the ‘Good workstation principles’ illustration on page 3.

Assessment checklist Work organisation

2

YES

NO

Unsure N/A

1. Does the user have a suitable variety of tasks? 2. Is care taken to avoid placing the user under excessive pressure to meet demanding work targets or deadlines? 3. Does the user have adequate control over the order in which tasks are completed? 4. Has workload been at an acceptable level recently? 5. If the user is a new staff member, or has recently returned from leave, did he/she have time to adjust to the workload? 6. Are work pauses being taken as appropriate? Chair 7. Is the chair easily adjusted from the seated position? 8. Is the seat height adjusted so that the user’s thighs are parallel to the floor with feet resting on the floor or on a footrest? 9. Is the back rest height adjusted to fit into the lower back? 10. Is the back rest angle adjusted so that the user is sitting upright while keying? Desk 11. Are the user’s forearms parallel with the floor when keying? (This can be achieved by lowering the desk to suit the user, or, with a fixed-height desk, raising the chair.)

12. Can the user get close to the workstation without Impediment? (Check that the desktop is thin, chair arms are not in the way and there is clear leg room.)

13. Is the desk height adjustable? If YES, is the adjustment easily operated? If NO, does the user need a footrest? 14. Is the footrest large enough to support both feet and allow a change of position? Counter 15. Is a suitable chair and foot support provided at the counter where sitting/standing work is performed?

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OH4

Keyboard workstation assessment continued

Assessment checklist continued Documents

2

YES

NO Unsure N/A

16. Are all source documents legible? 17. Is a document holder provided? 18. Does the holder support all source documents adequately? 19. Can documents be manipulated easily as required? Screen 20. When sitting and looking straight ahead, is the line of sight at the top of the screen? 21. Is the screen at a suitable reading distance? 22. Are all characters in the display easily legible and is the Image stable? 23. Can the position and contrast of the screen be adjusted by the user? Keyboard 24. Is the keyboard detached from the screen to ensure an efficient working position? 25. Is the keyboard thin enough for correct positioning of the arms? (It should be less than 30mm thick at the home row of keys.)

26. Are the keys matt finished to prevent Irritation from reflection? Layout 27. Are all often-used items within easy reach? (They should be within normal arm reach with minimum trunk movement.)

28. Is there sufficient space for large documents, completed work and/or writing to be done? 29. Is there sufficient space for CAD furniture, equipment and hardcopy materials? 30. Is the workstation designed to prevent undue twisting of the neck or trunk? 31. Is the variety of tasks performed in counter operations accommodated by the design and layout of the counter workstation? Environment 32. Does the user find the lighting satisfactory? (Check glare, reflections and the ability to read documents.)

33. Does the user find the noise level conducive to concentration? 34. Does the user find the temperature and airflow in the room suitable? Telephone operations and headsets 35. Is there a headset available for continuous telephone operations? 36. Is the headset lightweight, adjustable and comfortable? 37. Does the telephone equipment include easily adjustable volume controls? 38. Is the telephone positioned to facilitate correct working posture? Organisational Issues 39. Does the organisation provide proper induction and training for keyboard users? 40. Does the organisation consult with users on work issues? 41. Does the organisation have appropriate OHSW practices, policies and procedures? 42. Has the user been pain-free over recent times in the following areas: a. neck/shoulder b. back c. arms/hands d. legs/feet

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OH4

Keyboard workstation assessment continued

Problems and suggestions Problems identified

3

User’s suggestions to improve the design of their workstation or work system

Assessor’s suggestions/comments

Assessor verification

4

Date of report

Name of assessor

Time

____/____/_________

am pm

Signature

GOOD WORKSTATION PRINCIPLES 1. Back support adjusted to support the small of the back.

5

2. Arms approximately horizontal and no wrist deviation.

20˚

7

3. Seat height adjusted to suit operator and screen height (assisted height adjustment facility required for multi use chair)

6 90˚ or more

4. Swivel base chair with 5 support points – castors are not recommended on smooth hard floors.

2 1

5. Viewing distance 450–500mm.

8

90˚ or more

12

6. Manuscript holder to be on the same height and angle as the screen. 7. Display screen angle to be adjustable.

9

8. Thighs not to be compressed. Minimum thigh clearance 180mm.

3 11

9. Waterfall front on seat. 10. Footrests may be required for short operators.

4

10

11. Height to home key row 720–750mm. 14. Cord to be kept out of the way.

PAGE

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OH4

Keyboard workstation assessment continued

Problems and suggestions Problems identified

3

User’s suggestions to improve the design of their workstation or work system

Assessor’s suggestions/comments

Assessor verification

4

Date of report

Name of assessor

Time

____/____/_________

am pm

Signature

GOOD WORKSTATION PRINCIPLES 1. Back support adjusted to support the small of the back.

5

2. Arms approximately horizontal and no wrist deviation.

20˚

7

3. Seat height adjusted to suit operator and screen height (assisted height adjustment facility required for multi use chair)

6 90˚ or more

4. Swivel base chair with 5 support points – castors are not recommended on smooth hard floors.

2 1

5. Viewing distance 450–500mm.

8

90˚ or more

12

6. Manuscript holder to be on the same height and angle as the screen. 7. Display screen angle to be adjustable.

9

8. Thighs not to be compressed. Minimum thigh clearance 180mm.

3 11

9. Waterfall front on seat. 10. Footrests may be required for short operators.

4

10

11. Height to home key row 720–750mm. 14. Cord to be kept out of the way.

PAGE

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OH3

This form is used by DTF personnel to report any incidents/accidents, in order to take appropriate action to correct unsafe conditions or acts.

Incident report Employee to do: 1 – 9 Please provide your personal information, details, cause and nature of the incident and names of witnesses. Describe your injury and provide details of medical treatment if any. After signing, please forward to your supervisor.

Has an ee Please employ on help us t r got hu ? prevent y dut this event

Supervisor to do:

Any questions? Call: OHS&W Services, Corporate Services Telephone 08 – 8226 3520

10 – 12 Please describe the circumstances and any

happening again by providing details according to these steps.

factors contributing to the incident, then together with the Health and Safety Representative and the employee set up a plan for recommended action. Branch Head to do:

13 Please describe any further action required.

Send the completed form to: OHS&W Services, Corporate Services Level 3, State Administration Centre 200 Victoria Square Adelaide SA 5000

Parts 1–9 to be filled in by the employee Employee

1

Surname

Gender Male Female

First name

Age 19 or under 20–29

50–59 Over 60

30–39 40–49

Preferred language English Other (please specify)

Branch/Section

Telephone number (w)

Position title

Supervisor/manager’s name

Employee number

Employment status Full-time Permanent Part-time Temporary

Classification

/ Hours of duty per week per fortnight

Telephone number (h)

Length of employment in workforce Less than 1 year 1–5 years More than 5 years

Casual Contract

Length of employment in this job Less than 1 year 1–5 years More than 5 years

Usual work location (eg. Level 3, SAC)

Incident details

2

Date of incident

Time

____/____/_________

Location am pm

What happened? (Please include the events that led to the occurrence of this incident.)

The incident resulted in Injury No injury Near miss Property damage

Incident was reported to:

Date reported ____/____/_________

(Name of Supervisor/Manager) PAGE

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>


OH3

Incident report continued

Witnesses Name of witness 1

Contact telephone number

Name of witness 2

Contact telephone number

3

No witnesses Cause of incident

4 1

What was the cause of the incident? Tick all relevant boxes. Fall from a height Hitting objects with a part of the body Being hit by moving objects Exposure to sudden sharp noise Repetitive movements â&#x20AC;&#x201C; please specify: Lifting Bending Stretching Reaching Twisting Other (specify below) Exposure to radiation Aggression Other, multiple or unspecified actions (please describe)

Fall on a level surface â&#x20AC;&#x201C; slip or trip Exposure to mechanical vibration Manual handling equipment Long term exposure to noise Contact with electricity Single contact with chemical Shock/anxiety (eg. critical incident) Vehicle accident during work

Injury details If an injury was sustained, what part of the body was affected? Tick all relevant boxes. You may use the space below to specify.

5 1

Head and face Eye Ear Left Left Right Right Skull Other

Nose Face

Back and neck Neck Back Trunk

Hips and legs Hip Groin Left Right

Feet and toes

Hands and fingers

Foot Left Right

3rd toe Left Right

Hand Left Right

Ring finger Left Right

Thigh Left Right

Leg Left Right

Great toe Left Right

4th toe Left Right

Thumb Left Right

Little finger Left Right

Knee Left Right

Lower leg Left Right

2nd toe Left Right

5th toe Left Right

Forefinger Left Right

Middle finger Left Right

Ankle Left Right

Lower leg Left Right

Arms and shoulders Arm Left Right

Upper arm Left Right

Shoulder Left Right

Forearm Left Right

Elbow Left Right

Wrist Left Right

Internal and other Internal organ Multiple locations General locations Unspecified locations

> PAGE

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OH3

Incident report continued

What is the nature of your injury?

6 1

Fracture (excluding vertebral column) Dislocations Intracranial injury, including concussion Amputation including loss of eyeball Superficial injury Foreign body in eye/nose/respiratory/digestive system Injuries to nerves & spinal cord Effects of weather & pressure incl. electrocution Needlestick Stress, anxiety, shock Infectious Disease

Fracture of vertebral column Sprains & Strains of joints & muscles Internal injury of chest, abdomen and pelvis Open wound Contusion (bruising) with skin and crushing injury Burns Poisoning and effects of chemicals Multiple injuries Aggression Other and unspecified injuries Other diseases

Medical treatment and lost time Was any medical treatment sought/provided?

7 1

YES

If yes, name of medical provider

NO

Treatment date

Time am pm

____/____/_________ When the accident occurred, what percentage of your day had you worked? 0–25%

26–50%

51–75%

75–100%

Have you lost more than 1 full day of work time? If yes, have you returned to work? Have there been/will there be medical costs/expenses?

Overtime

YES

NO

YES

NO

YES*

NO

Uncertain at this time

* Note: if medical costs or expenses were incurred the incident becomes a workers compensation claim. In this event a WorkCover “Worker Report Form” must completed.

Incident verification Date

Employee’s signature

8

9

____/____/_________

Now forward this form to your immediate supervisor to complete the remaining parts of the report.

Thank you!

Please make sure this happens before the end of your day.

>

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OH3

Incident report continued

Parts 10–12 to be filled in by the supervisor/manager in consultation with the Health & Safety Representative and injured/reporting employee Investigation Were there any unusual circumstances at the time of the incident/accident?

10 1

YES

NO

If yes, please describe the events leading to the incident occurring

Did any of the following factors contribute to the incident/accident? (Please tick all relevant boxes.) No written procedure No training provided Lack of equipment Equipment not available Inadequate space Unsuitable work area

Incorrect method used Inadequate training provided Equipment fault Inappropriate equipment used Inadequate storage Possible lack of attention

Outdated method Needs on-going training Lack of equipment maintenance Inadequate ventilation/lighting Poor access Excessive workload

Risk control

11 1

To eliminate or minimise the risk of re-injury, five preferred risk control options exist. These are listed below left, in descending order. Together with a Health & Safety Representative and the reporting employee, please discuss and select the highest possible control option, then select the recommended action to achieve that objective. Please tick the recommended action/s:

Elimination Complete removal of the hazard or risk of exposure to the hazard, eg remove the problem/process

Substitution Involves replacing the hazardous plant, equipment, substance or work process with a less hazardous one

Engineering controls May include: using a redesigning/ re-engineering the workplace, fixing guards, or maintenance

Administration controls May include: introducing new work practices, policies, placing signs, training and operating procedures

Personal protective equipment

Change in induction program Change in on-going training Equipment/plant modifications Change to work procedure Change to work environment Equipment/plant maintenance Other job redesign Other preventative action

Proposed Proposed Proposed Proposed Proposed Proposed Proposed Proposed

Taken Taken Taken Taken Taken Taken Taken Taken

Post trauma counselling Exacerbation of a previous injury Action previously taken Rehabilitation required No change proposed

The use of safety shoes, goggles, splash glasses, gloves etc. are the least effective method of control but are sometimes required to protect employees from hazards in the workplace

Supervisor’s verification

12

The supervisor is responsible and accountable for ensuring that the appropriate action has been taken to minimise or eliminate the possible risk of injury or re-occurrence. I have taken the following action: Matter referred to Branch Manager Issue logged with OHS&W Services Employees consulted Estimated cost $

Supervisor’s signature

Date ____/____/_________

.

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OH3

Incident report continued

Part 13 to be filled in by the Branch Head Further action Is there any further action required?

13 1

YES

NO

If yes, please describe proposed action

Other comments

Date

Supervisorâ&#x20AC;&#x2122;s signature

____/____/_________

This part is to be signed by all involved parties Consultation

14 1

Health & Safety Representative Name

Signature

Date ____/____/_________

Reporting employee Name

Signature

Date ____/____/_________

Section Manager Name

Signature

Date ____/____/_________

OHS&W Services Name

Signature

Date ____/____/_________

Reset Form

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OH2

This form is used by DTF personnel to report and attend to any hazards identified in the workplace.

Hazard report Employee to do:

o Need t a t r o p re us o hazard n? io t situa

1

Fill in your personal details

Provide details of the hazardous situation, then pass the report on to your supervisor Supervisor to do:

2

Employee please fiMake ll out parts sure 1–2 all details are recorded by followingplease these Supervisor three simple fill out partssteps 3–5 Branch Head please fill out part 6

Any questions? Call:

3

Fill in your personal details

4

Provide further details of the hazardous situation

OHS&W Services, Corporate Services Telephone 08 – 8226 3520

5

Provide any follow up information then forward the report to your Branch Head

Send the completed form to:

Branch Head to do:

6

Further action required? Please specify, and then forward the report to the OHS&W Services

OHS&W Services, Corporate Services Level 3, State Administration Centre 200 Victoria Square Adelaide SA 5000

Parts 1 and 2 to be filled in by the employee Employee details Surname

First name

Branch/Section

Date of report

1 Time

____/____/_________

am pm

Details of the hazard

2

Where is the location of the hazard? (provide as much detail as possible to accurately describe the exact location)

What is the hazard? (describe the hazard in as much detail as possible)

What has been done to eliminate or control the hazard?

Have you advised others in the area of the hazard? YES NO NOT APPLICABLE

Do you have any ideas that may eliminate/control the hazard?

Please forward the completed form onto your supervisor now, to complete parts 3 to 5

Thank you! PAGE

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OH2

Hazard report continued

Parts 3â&#x20AC;&#x201C;5 to be filled in by the supervisor/manager Supervisor details Surname

First name

Telephone

Date hazard was reported to me

3

____/____/_________

Details of the hazard

4

Type of hazard Physical Chemical

Biological Ergonomic

Has the Health & Safety Representative been consulted?

Radiation Psychological

YES

NO

What temporary/permanent control measures have been implemented to solve the hazard? Elimination Substitution

Engineering Administrative

Other None

Please describe the control measure/s

Is any additional action required? YES (please describe)

NO

Who will do this?

When?

Follow up details

5

Follow up date ____/____/_________

Admin corporate services advised ____/____/_________

Has feedback been provided to the person who reported the hazard?

YES NO (please describe)

Parts 6 to be filled in by the Branch Head Further action

6

Send the completed form to:

Is any further action required? YES (please describe) NO

OHS&W Services Corporate Services Department of Treasury and Finance Level 3, 200 Victoria Square Adelaide SA 5000

Branch Headâ&#x20AC;&#x2122;s signature

Thank you!

Date

Reset Form

Save Form

Print Form

____/____/_________

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OH1

This form is used to conduct the quarterly site inspections, which are held to identify and attend to any hazards occurring in the workplace.

Quarterly

OHS&W Inspection Checklist & Action plan r Time fo rly e t r a u the q OHS&W ? ion inspect

Please take these five steps to conduct the inspection.

1

Provide site address, inspection time and the name/s of personnel involved

2

Please rate all areas on the checklist

3

Quoting the item number from part 2, please address any area that rated ‘poor’ or ‘fair’ in the action plan

4

The action plan needs to be endorsed by the OHS&W rep, involved staff members, their supervisor and the Branch Head

5

Any questions? Call: OHS&W Services, Corporate Services Telephone 08 – 8226 3520

Send the completed form to: OHS&W Services, Corporate Services Level 3, State Administration Centre 200 Victoria Square Adelaide SA 5000

Please return the completed form to OHS&W Services.

Inspection details Site address (eg. Level 3, State Administration Centre, 200 Victoria Square)

1 Inspection date

Time

____/____/_________

am pm

Name of Health & Safety Representative Name of Manager/Supervisor

Name of staff member

Workplace rating

2

Coding Criteria: L Poor = significant hazard/s identified K Fair = negligible hazard/s identified J Good = no hazard/s identified Please tick the appropriate box to rate the workplace condition. For further information relating to how to assess each area, please refer to the Worksite Inspection Reference Guide (COR052). NOTE: Any areas rating ‘poor’ or ‘fair’ need to be addressed in the Action Plan 2.1

General cleanliness and housekeeping

2.2

Building and environment

2.3

Furniture and fittings

2.4

Equipment and minor plant

2.5

Hazardous substances

2.6

Electrical

2.7

Manual handling

2.8

Emergency procedures and planning

2.9

Training

Please e thes p re ort the in s area plan action af le r e ov

2.10 OHS&W management systems

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L

K

J

Poor

Fair

Good

>


OH1

Quarterly

OHS&W Inspection checklist & Action plan continued Please ge is pa y p co th have u o if y han more t to 5 items t repor

OHS&W Action plan

3

Please list here – in order of priority – any problems that you identified during the OHS&W inspection by transferring the item number of any area that scored ‘poor’ or ‘fair’ from previous page. Item no

Item description

Major injury risk / Action deadline Potentially fatal High risk Low risk Negligible

Nominate person responsible for action

Immediate One week Two weeks One month

Complete by date ____/____/_________ Follow-up date ____/____/_________

Comments

Item no

Item description

Major injury risk / Action deadline Potentially fatal High risk Low risk Negligible

Nominate person responsible for action

Immediate One week Two weeks One month

Complete by date ____/____/_________ Follow-up date ____/____/_________

Comments

Item no

Item description

Major injury risk / Action deadline Potentially fatal High risk Low risk Negligible

Nominate person responsible for action

Immediate One week Two weeks One month

Complete by date ____/____/_________ Follow-up date ____/____/_________

Comments

Item no

Item description

Major injury risk / Action deadline Potentially fatal High risk Low risk Negligible

Nominate person responsible for action

Immediate One week Two weeks One month

Complete by date ____/____/_________ Follow-up date ____/____/_________

Comments

Item no

Item description

Major injury risk / Action deadline Potentially fatal High risk Low risk Negligible

Nominate person responsible for action

Immediate One week Two weeks One month

Complete by date ____/____/_________ Follow-up date ____/____/_________

Comments

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OH1 4

Quarterly

OHS&W Inspection checklist & Action plan continued

Please ge is pa y p co th have u o if y han more t to Outstanding/Unresolved issues 5 items t repor All outstanding/unresolved hazards or problem areas identified during past quarterly safety inspections are to be documented in the space provided together with an order of priority in which you believe the problem should be addressed and evidence of any progress made to-date.

Item no

Item description

Major injury risk / Action deadline Potentially fatal High risk Low risk Negligible

Nominate person responsible for action

Immediate One week Two weeks One month

Complete by date ____/____/_________ Follow-up date ____/____/_________

Comments

Item no

Item description

Major injury risk / Action deadline Potentially fatal High risk Low risk Negligible

Nominate person responsible for action

Immediate One week Two weeks One month

Complete by date ____/____/_________ Follow-up date ____/____/_________

Comments

Item no

Item description

Major injury risk / Action deadline Potentially fatal High risk Low risk Negligible

Nominate person responsible for action

Immediate One week Two weeks One month

Complete by date ____/____/_________ Follow-up date ____/____/_________

Comments

Item no

Item description

Major injury risk / Action deadline Potentially fatal High risk Low risk Negligible

Nominate person responsible for action

Immediate One week Two weeks One month

Complete by date ____/____/_________ Follow-up date ____/____/_________

Comments

Item no

Item description

Major injury risk / Action deadline Potentially fatal High risk Low risk Negligible

Nominate person responsible for action

Immediate One week Two weeks One month

Complete by date ____/____/_________ Follow-up date ____/____/_________

Comments

NOTE: OHS&W Services will report this Section to the OHS&W Committee.

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OH1

Quarterly

OHS&W Inspection checklist & Action plan continued

Endorsements

5

OHS&W representative Name

Position/title

Signature

Date ____/____/_________

Other staff members Name

Position/title

Signature

Date ____/____/_________

Name

Position/title

Signature

Date ____/____/_________

Director/Manager Name

Position/title

Signature

Date ____/____/_________

Branch Head Name

Position/title

Signature

Date ____/____/_________

6

Send the completed form to: OHS&W Services, Corporate Services Level 3, State Administration Centre 200 Victoria Square Adelaide SA 5000

Thank you!

Need help?

NOTE: If you require support to implement corrective action, please send a copy of the completed report to Administrative Services

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HR16

This form is used to gain authorisation for leave entitlements.

Application for

Leave of absence Time to take a break?

Make sure all details are recorded correctly by following these simple steps

1

Provide your details

2

Specify the type and length of leave you are applying for, then follow through to the question indicated to provide further details in parts A â&#x20AC;&#x201C; D

Any questions regarding completion of this form? Call: Human Resources Telephone 08 â&#x20AC;&#x201C; 8226 3135

Send the completed form to: DTF Human Resources for approval

3

Sign the form and send to Payroll

!

Attach Medical certificate where required

Employee

1

Surname

First name

Branch/Section

Employee number

Type and length of leave

2

Recreation leave Sick leave with pay Family care leave Special leave with pay Special leave without pay Long service leave

Length

Go to Part A Go to Part B Go to Part B Go to Part C

Start date

working days hours (sick leave and family care leave only) calendar days (long service leave only) End date

Go to Part C

____/____/_________

Go to Part D

Flexi day 1 Flexi days included

Provide details at right

____/____/_________

____/____/_________ Flexi day 2 ____/____/_________

Recreation leave Type of recreation leave

A

Normal recreation leave Advance pay I request pay in advance

Note that applications should be made at least four weeks before the leave is to start, if pay in advance is required.

Declaration I declare that I have accrued sufficient leave for the absence desribed above. I understand that this leave is granted on the basis that if I leave the Public Service before completing service appropriate to the amount of leave taken, I will refund the monetary equivalent of the excess leave taken. Go to Part 3

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HR16

Application for

Leave of absence continued

Sick leave Type of sick leave

B

Sick leave with pay Family care leave

Applications for sick leave over 3 consecutive working days must be accompanied by a medical certificate. Sick leave without pay is to be applied for as special leave without pay. An employee may access up to 5 days of their current sick leave entitlement per financial year to care for a family member. See DTF Policy Statement for details.

Medical certificate Attached Not attached Go to Part 3

Special leave

C

Type of special leave Special leave with pay

Please provide reason below.

Special leave without pay

Please provide reason below (including sick leave without pay)

Medical certificate Attached Not attached

Go to Part 3

Long service leave

D

Type of long service leave Normal long service leave

LSL is available after completion of 10 years effective service. Go to part 3

Other long service leave

If you wish to apply for long service leave using other arrangements such as half pay, please contact Human Resources on 8226 3135.

Signature

3

Employeeâ&#x20AC;&#x2122;s signature

Approval Date

Delegateâ&#x20AC;&#x2122;s signature

____/____/_________ Contact phone number during leave

Date

Thank you!

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____/____/_________ Please ensure adequate leave is available prior to signing.

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HR15

This form is used by Human Resources to advise Payroll of employeeâ&#x20AC;&#x2122;s salary account details.

Employee

Salary disbursement o Make sure Need t ur o y all details are e id iv d tween recorded by pay be ent following differ ? these three ts n u o c c a simple steps

Any questions regarding completion of this form? Call: 1

Fill in your personal details

2

Provide the relevent account details

3

Sign the form

Human Resources Telephone 08 â&#x20AC;&#x201C; 8226 3135

Send the completed form to: DTF Human Resources for approval

Employee Surname

First name

Branch/Section

Employee number

1

Please k -chec double ount cc your a rs! numbe

Salary disbursement

2

Account 1

Financial institution and branch location

BSB number

Amount to go to Account 1

Account number $

Account 2

Financial institution and branch location

BSB number

. All

Account number

Amount to go to Account 2 $

Account 3

Financial institution and branch location

BSB number

. Balance

Account number

Amount to go to Account 3 $

Account 4

Financial institution and branch location

BSB number

. Balance

Account number

Amount to go to Account 4 $

. Balance

Signature I request that my salary be disbursed as detailed above

Date

3 ____/____/_________

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HR14

This form is used by Human Resources to keep an up-to-date record of leave loading conversions.

Conversion of leave loading to 2 days annual leave wo Want t ra t x e s day annual leave?

If you’d like to swap your leave loading to two days of extra annual leave, follow these steps

Any questions regarding completion of this form? Call: Human Resources Telephone 08 – 8226 3135

1

Complete personal details

Send the completed form to:

2

Sign and forward to Human Resources

DTF Human Resources for approval

Employee Surname

First name

Branch/Section

Employee number

1

2

Signature

Payroll services use only

I hereby elect to receive two additional days recreation leave annually in lieu of receiving payment of leave loading.

Payroll representative’s signature

Signature

Date ____/____/_________

Date ____/____/_________

Thank you! Reset Form

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HR13

This declaration is required from all applicants for a Public Sector Management Act position (if that person is not already employed in the Public Service) before a decision is made to appoint that person.

Declaration on Application for Employment in the South Australian Public Sector All job g applicants Applyin b to DTF for a jo ? are required F T D t a to fill out this declaration and attach it to their application. Please follow these steps

A + B Provide details of yourself and the position you are applying for 1

Please answer all questions regarding issues to be declared on application

2

Thoroughly read through the declaration and if you agree with it, please sign at the bottom

!

Once completed, please attach this form to your application

Any questions regarding completion of this form? Call: Human Resources Telephone 08 â&#x20AC;&#x201C; 8226 3135

Send the completed form to: DTF Human Resources for approval

Applicant Surname

First name

A Post code

Home address

Position

B

Title of position you have applied for

Branch/Section

Issues to be declared on application to DTF

1

a) Do you currently have any disability or medical condition which might prevent or impede you from being able to satisfactorily perform any duties that might be required of you in the position for which you have applied? NOTE: This question is further explained in Note 1 on page 4 of this form.

NO YES Unsure

Go to next question Provide details below Provide details below

Please include details of any assistance/adjustments that would allow you to carry out the functions of the position. If you have any disability or medical condition which might require the provision of non standard measure to either provide you with a safe system of work, or to enable you to satisfactorily perform your duties, you should tell us. This information is necessary to enable us to provide a safe system of work to you in the event that you are offered employment, and to enable us to provide appropriate assistance. The provision of any such information will not be used to discriminate against you because of the existence of any such disability or medical condition.

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HR13

Declaration on Application for Employment in the South Australian Public Sector continued

Issues to be declared on application to DTF continued

1

b) If you are offered the position, do you agree to undergo a medical examination that relates to the functions of the position? NOTE: This question is further explained in Note 1 on page 4 of this form.

YES NO c) Have you ever been convicted of an offence? NOTE: This question is further explained in Note 2 on page 4 of this form.

NO YES

Go to next question Provide details below

d) Are you currently facing charges yet to be determined for any offence? NOTE: This question is further explained in Note 2 on page 4 of this form.

NO YES

Go to next question Provide details below

e) Have you ever received any voluntary early retirement or voluntary separation package from the South Australian public sector*? NOTE: This question is further explained in Note 2 on page 4 of this form.

NO YES

Go to next question Provide details of resignation date and name of issuing agency/authority below

Agency/Authority

Resignation date ____/____/_________

f) Have you ever received any payment, involving your resignation from South Australian public sector* employment, in redemption of a liability under the South Australian workerâ&#x20AC;&#x2122;s compensation legislation? NO YES

Go to next question Provide details of resignation date and name of issuing agency/authority below

Agency/Authority

Resignation date ____/____/_________

*

Public sector in relation to such packages means any agency or instrumentality of the Crown in right of the State of South Australia and includes any body corporate that is in existence or which is established by or under any Act and which is subject to control or direction by a Minister.

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HR13

Declaration on Application for Employment in the South Australian Public Sector continued

Applicant declaration

2

a) I acknowledge that, if my application for employment in the South Australian public sector is successful and I am employed in the public sector either in the position for which I have applied or in any other position, I may, during the course of that employment, gain access to information. Detailed provisions regarding disclosure of confidential information are contained in relevant public sector guidelines and regulations. Without detracting from any such guidelines or regulations, unless such information is clearly not of a confidential nature, and unless I am expressly advised to the contrary by appropriate supervisors, all such information is to be treated as confidential. The expression â&#x20AC;&#x153;confidential informationâ&#x20AC;? as used in this declaration means all information which must be treated as being of a confidential nature. I understand that I must not disclose or make use of that confidential information, during or after that employment, except in the proper course of my duties. In particular, I undertake not to use any confidential information gained by virtue of any public sector employment, with the intent of securing a benefit for myself, any person, company or any future employer. b) I undertake that, if my application for employment in the South Australian public sector is successful and I am employed in the public sector either in the position for which I have applied or in any other position, I will not engage in any external or private activities which will result in a conflict or potential conflict of interest with any of my duties as a public sector employee. Detailed provisions regarding disclosure of confidential information are contained in relevant public sector guidelines and regulations. Without detracting from any such guidelines or regulations, in any case where there is any possible doubt regarding a potential conflict of interest, I undertake to seek advice and instruction from an appropriate supervisor. c) I understand that, if my application for employment in the South Australian public sector is successful and I am employed in the public sector either in the position for which I have applied or in any other position, the offering of employment to me in the public sector will be expressly on the basis that the information that I have provided in relation to my application for employment is true and correct in every detail. I understand that any incorrect statement in my application or interview for employment on any matter relevant to my employment in the public sector, including (but not restricted to) my qualifications, experience, ability, physical or mental health or personal integrity, may make me liable to disciplinary action which may include dismissal. d) I declare that the information in this declaration and in any other documents completed by me in support of my application for employment in the South Australian public sector, and the information provided by me during any interviews in connection with my application for employment in the South Australian public sector, is true and correct in every detail. e) To the best of my knowledge all information disclosed in response to the questions in this declaration is true and correct in every respect.

Applicantâ&#x20AC;&#x2122;s signature

Date ____/____/_________

Print name

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HR13

Declaration on Application for Employment in the South Australian Public Sector continued

Use of Information Disclosed in the Declaration on Application for Employment in the South Australian Public Sector There is certain information which an agency must obtain from an applicant for a Public Sector Management Act position (if that person is not already employed in the Public Service) before a decision is made to appoint that person.

NOTE 1: Questions 1 (a) and 1 (b) Disabilities or Medical Conditions Under equal opportunity legislation it is illegal to require an applicant to disclose details of disabilities or medical conditions which are not relevant to the duties of the position or the workplace (including past work injuries and conditions). Question 1(a) of the Declaration on Application for Employment has been drafted to avoid this implication.

This information falls into one of two categories: •

issues which may impact on the suitability of the applicant for the position; or

issues related to Government public sector workforce policy.

The Office for the Commissioner for Public Employment, together with the Crown Solicitor’s Office and the Equal Opportunity Commission, has developed a Declaration on Application for Employment that should be completed by applicants for positions who are not already employed in the Public Service (refer to Appendix 2). All such applicants who will be interviewed for the position should be sent a Declaration when an interview is arranged. The Declaration should be returned by the applicant to the agency before the interview so that any relevant disclosures in the Declaration can be raised and discussed at the interview. Issues addressed by the Declaration are relevant to the eligibility and capacity of the employee to undertake the functions of the position.

It is important that an applicant has access to the job and person specification when responding to question 1(a). The job and person specification should accurately outline the outcomes of the position to enable the applicant to properly answer the question. In some circumstances it may be appropriate to require a medical examination to determine whether an applicant is able to perform the functions of the position. The medical examination should only be conducted for an applicant (including an applicant who has answered ‘yes’ or ‘unsure’ to the question relating to disabilities or medical conditions) who is the best candidate for the position. Where a medical examination will be conducted for the best candidate, it is acceptable practice to make an offer of employment conditional upon successful completion of the examination.

All disclosures made by an applicant in the Declaration should remain private and confidential. Any disclosed information should only be used to determine whether the applicant is qualified, capable and able to hold the position having regard to the applicant’s qualities and Government workforce policies.

Any medical examination must be agreed to by a candidate and conducted by a fully qualified professional.

The examination must specifically relate to the capacity of the candidate to undertake the duties of the position and should not be conducted as a general test of health.

Even if the applicant has a disability or condition which does affect their capacity to perform the position’s functions, this does not necessarily exclude the applicant from being the successful candidate. Under the South Australian Equal Opportunity Act 1984 and the Commonwealth Disability Discrimination Act 1992 an employer may be required to make ‘reasonable adjustments’ to allow a person with a disability to perform a job. This may include adjustments to access, workplace design, modifications to equipment, job redesigning and work schedule restructuring. If you need further advice on what constitutes ‘reasonable adjustment’ contact the Equal Opportunity Commission.

NOTE 2: Questions 1(c) and 1 (d) Criminal Offences and Current Criminal Charges Information disclosed in respect of criminal offences or current criminal charges should only be taken into account where the offences committed or alleged to have been committed by the applicant are relevant to the duties of the position. Offences which have no bearing on the suitability of the applicant having regard to the functions of the position should be disregarded. In some circumstances it would be appropriate to obtain a formal record of an applicant’s criminal history (if any). This would be appropriate where the functions of the position are such that absolute certainty and accuracy is required in respect of any past criminal conduct by the applicant (for example, where the duties involve supervision, care of or work with children).

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HR13

Declaration on Application for Employment in the South Australian Public Sector continued

Use of Information Disclosed in the Declaration on Application for Employment in the South Australian Public Sector continued The Records Release Unit of the SA Police Department is the body responsible for providing Police History Offender Checks. There are two methods of obtaining this check. •

The first method is pursuant to a standing arrangement between a Government Agency and the Police Records Release Unit. This standing arrangement is formalised in a Memorandum of Understanding in which the Government Agency agrees to certain procedures for obtaining and using the Police History Offender Check. Under the standing arrangement agencies have the capacity, with the written consent of the applicant, to directly obtain a Police History Offender Check from the Records Release Unit.

Under the Targeted Voluntary Separation Package Scheme, an employee receiving a package agrees to the following conditions: 1. voluntary resignation from their public sector position; and 2. not to apply for, accept, engage in, or remain in public sector employment for a period of three years from the date on which the employee’s resignation takes effect. Commissioner’s Direction 2 – Recruitment and Appointment of Non-Executive Employees states that a person who has accepted a separation package on these terms must not be re-employed in the public sector until the three year ‘no re-employment’ period expires. This requirement ensures that the Scheme remains a cost effective way of adjusting the public sector workforce and prevents the situation where an employee resigns, only to be re-employed within a short period of time, when an agency finds it still requires the skills, knowledge and experience of the former employee.

Many Government Agencies with an ongoing need to access Police History Offender Checks on applicants have already established a standing arrangement with the Records Release Unit. If your agency does not have such a standing arrangement but does have an ongoing need to access Police History Offender Checks, a formal request in writing can be made to the Police Records Release Unit outlining your agency’s need for ongoing access. •

NOTE 3: Question 1 (e) Separation/Voluntary Retirement Packages from the South Australian Public Sector

The second method of obtaining a Police History Offender Check is to request the applicant to provide the document. All members of the public are entitled to obtain their own Police History Offender Check for a set fee, by making an application in writing at any police station. If your agency has only an occasional need to access the Police History Offender Checks of applicants, this may be the appropriate course to follow.

The information disclosed in response to question 1(e) of the Declaration should only be used to determine whether a three year ‘no re-employment’ period is current. If you need to clarify whether a ‘no re-employment’ period is current, contact the agency from which the employee separated. NOTE 4: Question 1 (f) Lump Sum Capital Payment Under Workers’ Compensation and Rehabilitation Act Involving Resignation from the South Australian Public Sector

Please note a Police History Offender Check may include the outcome of charges even if they are outcomes where no conviction was recorded. Where a charge has been found proven but no conviction has been recorded, agencies should note that the Court has considered the matter to be so trivial as to not record a conviction. Therefore, it would be only in exceptional circumstances that such a matter would be relevant to employment considerations. The employment declaration signed by an applicant does not require them to disclose unrecorded convictions and any absence of this information on the declaration should not be considered an indication of bad faith on the part of that applicant.

Under the Worker’s Compensation and Rehabilitation Act 1986, a public sector employee who is entitled to compensation payments for a work injury, may negotiate a lump sum capital payment in relation to employment within the public sector. These lump sum capital payments can be similar to a separation package as the employee may: 1. voluntarily resign from their Public Sector position; and 2. agree not to apply for, accept, engage in, or remain in Public Sector employment for a period of three years from the date on which the employee’s resignation takes effect.

A Police History Offender Check may reveal sensitive information. To ensure fair treatment of employees and prospective employees the information must be used appropriately and only in circumstances where it is relevant. If you are unsure of whether the information is relevant please contact the Office for the Commissioner for Public Employment on 8226 2196.

A person who has accepted such a lump sum capital payment on these terms must not be reemployed in the Public Sector until the three year ‘no re-employment’ period expires. The information disclosed in response to question 1(f) of the Declaration should only be used is to determine whether a three year ‘no reemployment’ period is current. If you need to clarify whether a ‘no re-employment’ period is current, contact the Government Workers’ Rehabilitation and Compensation Office.

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HR12

This form is used for short term situations of up to 12 months, eg. backfilling while someone is on leave, or filling a position temporarily.

Temporary placements g Needin e nis a g r o o t orary a Temp nt? me Assign

If a member of your staff is being temporarily assigned to another position, just follow these steps

1

Provide employee’s details

2

Provide details of employee’s current position as well as the temporary assignment position

3

Fill in possible position advertising details

4

Please specify remuneration level

5

Get DTF Branch Head and HR approvals

Any questions regarding completion of this form? Call: Human Resources Telephone 08 – 8226 3135

Send the completed form to: DTF Human Resources for approval

Employee Surname

First name

Branch/Section

Employee number

1 Classification

/

Temporary placement details

2

This assigment is from the position of (Position title)

Position number

To the position of (Position title)

Position number

Current occupant (if applicable)

Employee number

Start date

Original commencement date

____/____/_________

End date (inclusive) ____/____/_________

____/____/_________ Note: Fill in the date if this form is to extend an existing temporary assignment.

Reason for assignment

Position advertising Was this position advertised in the Notice of Vacancies?

3

YES Vacancy number

NO Advertisement date ____/____/_________

Note: If the position was not advertised in the Notice of Vacancies the assignment period can not be longer than 12 months from the date of commencement. An extension that results in the aggregate assignment period being greater than 12 months will require the position being advertised in the Notice of Vacancies.

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HR12

Temporary placements continued

Remuneration Classification level:

4

/

Next increment date ____/____/_________

NOTE: The default remuneration will be to the 1st step of the higher classification level. The approval of the Under Treasurer is required to go above this parameter.

DTF approvals

3

Branch Head or Delegateâ&#x20AC;&#x2122;s signature

Payroll Services Pay Period ending

Date ____/____/_________

____/____/_________ DAIS Payroll representativeâ&#x20AC;&#x2122;s signature

Thank you! Date ____/____/_________

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HR11

This form is used by Human Resources to make sure the department always has current personal and emergency contact details for all DTF employees.

Personal and emergency Contact details new employees only o Need t ur o y change act t n co ? details

Remember to fill out a new form whenever any of your details change

1

Enter today’s date

Any questions regarding completion of this form? Call:

2

Provide your personal details

3

Please provide details of the person you would like to nominate as your emergency contact

Human Resources Telephone 08 – 8226 3135 DTF Human Resources for approval

l a i t n e d fi n o C

Date

1

Send the completed form to:

The information provided below is valid as of Date ____/____/_________

ept in to be k

al file

person

Employee’s personal details

2

Surname

g Existin s e e y emplo nge a h c are to etails their d iosk using K

First name

Home telephone number

Mobile telephone number

Employee number

Home address

Emergency contact person

3

Surname

First name

Home telephone number

Work telephone number

Mobile telephone number

Address

Relationship to employee Partner/spouse

Parent/guardian

Daughter/son

Friend

Doctor/carer

Reset Form

Save Form

Other

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HR10

This form is used by employees to gain authorisation for reinbursement of study fees.

Application for

Reimbursement of study fees d Finishe your s? subject

If you wish to apply for reimbursement of your study fees, please follow these steps

1

Provide your personal details

2

Fill in your study results

Any questions regarding completion of this form? Call:

3

Provide details of your study fees

4

Sign the form

Human Resources Telephone 08 â&#x20AC;&#x201C; 8226 3135

5

Send the form to Human Resources

Send the completed form to: DTF Human Resources for approval

Employee

1

Surname

First name

Branch/Section

Course title

Institution

Results of studies Subject

Result Completed Withdrawn

2

Completed Withdrawn Completed Withdrawn Completed Withdrawn Completed Withdrawn Completed Withdrawn Please attach official evidence of your results

Attached

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HR10

Application for

Reimbursement of study fees continued

Fee details

3

Upfront HECS Tax

$

Upfront/Institution fees (without union or administration fees)

$

Other fees (please specify)

$

Total

$

0.00

Please attach a receipt of payment for all the fees you are claiming

Attached

Applicant’s signature

4

I hereby apply for reimbursement of the fees listed below and: 1. Understand that reimbursement will be to a maximum of 75% of the subject upfront fee or upfront HECS tax; 2. Declare that the information in this application is correct, and 3. Understand that the reimbursement is only paid to me on the basis that the course I am undertaking is in relation to the earning of my assessable income as an employee of Department of Treasury and Finance. Signature

Date ____/____/_________

5

Send the completed form to: Human Resources Department of Treasury and Finance Corporate Services Level 3, 200 Victoria Square Adelaide SA 5000

Thank you!

Authorisation Reimbursement of the following amount is approved $

.

Account number

Signature to authorise payment required. Branch Manager’s signature

Date ____/____/_________

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HR9

This form is used to obtain authorisation to undertake study leave.

Application for

Study leave Need time to study?

Make sure all details are recorded correctly by following these six simple steps

Any questions regarding completion of this form? Call:

1

Provide your personal details

2

Fill in your existing qualifications

3 4

Fill in details of the study you intend to undertake Sign the form

5

Obtain a recommendation from your Superviser

6

Obtain a recommendation from your Branch Manager

!

Don’t forget to read the notes provided for help

Human Resources Telephone 08 – 8226 3135

Send the completed form to: DTF Human Resources for approval

Employee

1

Surname

First name

Contact phone number

Position type Full-time Part-time

Hours of duty

Contract type Permanent Temporary

Classification

Branch/Section

per week per fortnight

/

Existing qualifications – post-secondary studies already completed

2

Course title

Qualification

Year completed

Details of course now to be undertaken Course title

3 Qualification/degree awarded at completion

Institution

Total number of subjects/units in this course

Campus location

No of subjects/ units you have already completed

No of subjects/ units you have yet to complete

What year did you start this course?

What year do you expect to complete this course?

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HR9

Application for

Study leave continued 3 See pg lp e h r fo is with th n io t c e s

Details of course now to be undertaken continued

3

Repeat subject

Subject

No of weeks

Lecture start time

Time off work (5,7

Travel time (8

Time to Own make up (9 time (10

YES NO

am pm

h

h

h

h

YES NO

am pm

h

h

h

h

YES NO

am pm

h

h

h

h

YES NO

am pm

h

h

h

h

YES NO

am pm

h

h

h

h

TOTAL

0

h

0

h

0

h

0

h

Applicant’s signature

4

Date

Signature

____/____/_________

Supervisor/Manager’s comments

5

I have counselled the employee in relation to undertaking the studies specified above, and consider the applied study leave Recommended Not recommended Supervisor’s signature

Date ____/____/_________

Branch Manager’s comments

6

Study leave of

hours per week (12 is hereby

Approved Not approved On successful completion, reimbursement (13 of fees will be at Branch Manager’s signature

% (refer to study policy) Date ____/____/_________

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HR9

Application for

Study leave continued

Notes to help you complete this form

1. It is unlikely that all requests for study leave will be able to be supported to the same extent. Managers should therefore be mindful of the relevance of the course of study in relation to Branch Business Plan, the employee’s PMP Development Plan, the key functions performed within the Branch, and to the career aspirations of the individual, when deciding the degree of support relevant to each application. The degree to which fees may be reimbursed should be considered in the light of other training and development priorities, and decided at the time of the PMP process and approving an application.

7. For each subject, show the number of combined hours for lectures and tutorials. 8. State the number of hours (to the nearest 0.25) travelling time requested between 8.45 am and 5.00 pm. 9. If an employee requests time off in excess of the number of hours which their manager is prepared to agree to, the employee may offer to make up the additional time by using flexitime system to work additional hours. Managers and employees should both be aware that this becomes difficult to achieve when studying on a part-time basis.

2. An employee wishing to undertake studies which will require leave during working hours is required to obtain their manager’s approval in principle PRIOR to enrolling in the course. When lecture/tutorial times are finalised this form is to be completed and forwarded to the Branch Manager.

10. Over the length of a course an employee is expected to attempt to undertake the same number of contact hours in their own time, as they seek to undertake during working hours.

3. An employee undertaking studies solely in their own time is encouraged to complete this form to enable the department’s Chris Training and Development database to reflect all skills and qualifications possessed by employees.

11. An employee first commencing a course of study should be counselled by their manager regarding the relevance of the course to the operations of the branch, the department, or the public sector generally, and to their own career development. Assistance can also be sought from the HR Section.

4. Semester based subjects will necessitate a new application each semester.

12. This figure includes time off with pay, plus travelling time.

5. For the purpose of calculating ‘time off during working hours’, standard hours of work are 8.45 am to 5.00 pm.

13. The degree of financial support afforded to each employee will vary according to circumstances.

6. Time off with pay is at the branch manager’s discretion, but should not normally exceed 5 hours per week, plus reasonable travelling time.

14. When this application has been signed by the branch manager it is to be forwarded to the HR Section for updating the employee’s Personal file.

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HR8

The purpose of this questionnaire is to assist Human Resources in identifying the key reasons for employee turnover.

Exit interview Making ? a move

Thank you for taking the time to fill out this questionnaire. It should take no longer than five minutes, and the responses are valuable to the department

1 – 2 3

Fill in your personal and service details

Please describe your career plans

4 – 7

8

Please rate your job satisfaction and describe your reasons for leaving Note: No information provided by you in this form will be revealed to any other prospective employer, either within the Government or in private enterprise If you have any improvement suggestions please let us know. Then return the completed questionnaire to Human Resources

Any questions regarding completion of this form? Call: Human Resources Telephone 08 – 8226 3135

Send the completed form to: DTF Human Resources

Your details Surname

First name

Branch/Section

Gender Male Female

1

Level of Education School Bachelor’s Degree TAFE Master’s Degree

Honors PhD

Age < 30 30–34 35–39

40–44 45–49 50–54

55–59 60+

Other

Your service at DTF and in the public sector

2

Length of service at DTF 0–4 years 5–9 years 10–14 years 15–19 years 20–24 years 25+ years

Total length of service in the public sector* 0–4 years 5–9 years 10–14 years 15–19 years 20–24 years 25+ years

Employment type**

Classification level ASO–1 ASO–2 ASO–3 ASO–4 ASO–5 ASO–6

ASO–7 ASO–8 MAS–1 MAS–2 MAS–3 Executive

Other

Permanent Contract/temporary Position type** Full-time Part-time ** at time of leaving

Name of last employer public sector* agency/branch before DTF

* Include State, Commonwealth, Local government and University employment

Your career plans

3

Your career destination on leaving DTF Other State public sector agency Other public sector employer Community or non-government sector Private business employee Own business Home duties Retirement Unknown at this time Other

Planned employment type Permanent Contract/temporary Planned position type Full-time Part-time

New salary level Higher than before Same as before Less than before Unknown at this time

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HR8

Exit Interview continued

Job satisfaction 1: Organisation

4

Please tick a box below the graph to show how often you felt that the following qualities were true at your organisation

Never

Always

N/A

Never

Always

N/A

a) I participated, with my manager, in a continuing process of Performance Management as described in the departmental guidelines b) I felt the senior leadership of the organisation had a clear vision and direction for the organisation c) The organisation gave me access to skills training to help me do my job better d) The organisation provided me with adequate opportunities for personal development e) I could see opportunities for promotion in my agency or the broader public sector f) I felt the salary for my job was right for the responsibilities I had g) The organisation recognised when staff did good work h) Management in the agency generally supported my work and that of my team i) I could get things done without too much â&#x20AC;&#x2DC;red tapeâ&#x20AC;&#x2122; j) If necessary senior management staff were available to talk about issues in my work k) I was kept informed of changes in the organisation which would affect me l) I was encouraged to participate in organisation change strategies

Job satisfaction 2: Your branch/unit/area

5

Please tick a box below the graph to show how often you felt that the following qualities were true at your work location a) I was satisfied with the quality of the management and supervision within my work location b) I worked well with my colleagues c) My job was challenging and interesting d) My job was stimulating and I could learn from doing e) I enjoyed the level of contact with other people in my job f) I was encouraged to use my initiative in the course of my work g) I was able to use the full range of my skills, abilities and knowledge in my job h) My job provided sufficient variety i) I was able to cope with the level of stress and pressure in my job j) My job allowed me to balance the demands of work and family to my satisfaction k) My supervisor gave me adequate recognition for my work contribution

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HR8

Exit Interview continued

Job satisfaction 3: Overall satisfaction

6

Please tick a box below the graph to show how often you felt that the following qualities were true at your job

Never

Always

N/A

Very important

N/A

a) I felt I could be effective in my job b) I was satisfied with the quality of my working life in my last agency c) My immediate work environment was satisfying

Factors affecting my decision to leave

7

Please tick a box below the graph to indicate the importance of the following factors in your decision to leave your current position

Not important

a) Promotion or career advancement (including improved remuneration) b) Career change (including formal study; seeking a new challenge) c) Constant change and/or uncertainty d) Job eliminated and/or contracted out e) Personal reasons related to the job f) Personal reasons unrelated to the job g) Retirement h) Availability of redundancy package i) Other: Would you make the same decision today?

YES

NO

If the Department of Treasury and Finance advertised a position that you considered yourself suitable for, would you consider applying? Please comment.

YES

NO

What can we do better?

8

In your opinion, what is the most important area requiring attention or change in the Department? Please comment.

Please send the completed form to Human Resources

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you Thank ime t r u for yo ort! f f e d an nt partme The De you well wishes r new in you urs. o endeav

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HR7

This form is used by employees to formally notify DTF of their intention to cease as an employee.

Separation advice u Are yo n leavi g DTF?

Make sure all details are recorded correctly by following these three simple steps

Any questions regarding completion of this form? Call:

1

Provide your personal details

2

Please speficy your reason for separation

3

Sign the advice and then get authorisation from a DTF delegate, and send the completed form to Human Resources

Human Resources Telephone 08 – 8226 3135

Send the completed form to: DTF Human Resources

Employee

1

Surname

First name

Branch/Section

Employee number

Post code

Home address

Reason for separation

2

My reason for separation is Resignation Retirement Contract employment concluding Transferring to another agency (please specify):

Signatures

3

____/____/_________

Payroll Services

This advice authorises Payroll to cease me as an active employee of the above section from the effective date above. Employee’s signature

Effective from close of business on

Date ____/____/_________

Employee’s leave paid out Employee’s details updated Leave balance transferred Separation Certificate issued Terminated on CHRIS System Filed on Employee’s personal file Personal File closed/forwarded

I authorise this separation advice Delegate’s signature

Date

Prepared by

____/____/_________ Print name

Date ____/____/_________

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HR6

This checklist has been designed to assist Branch Managers in managing the permanent/ temporary departure of employees from the department. It highlights possible areas that could be overlooked when someone leaves.

Exit process checklist Staff r membe ? leaving

Completion of this checklist and reviewing all the information contained within will ensure a smooth and timely exit and minimise the Department’s exposure to risk

A + B Fill in employee and Supervisor’s details

Any questions regarding completion of this form? Call:

1 – 5 Go through this checklist with the employee verifying that all the tasks included have been undertaken and all DTF’s assets have been returned

Human Resources Telephone 08 – 8226 3135

6

Once completed, both of you will need to sign on the last page

7

Forward the signed list to Human Resources for filing in the employee’s personal file

Send the completed form to: DTF Human Resources for approval

ust be This m at least ted comple rs prior 24 hou orking w to last DTF day at

Employee and Supervisor Employee Surname

First name

Branch/Section

Employee number

Position title

Classification

A

/

Supervisor/Manager

B

Surname

First name

Exit process checklist Security

1

Have all Security Access Cards and Office Keys been returned?

YES

NO

It is important, especially for security access cards with 24h access, that cards are returned to Purchasing and Facilities Management for cancellation. Should an employee still require the card in a new role then please ensure that modifications are made via the Security Access Form available from Purchasing and Facilities Management or on the Intranet (Direct link to IAS/Key Documents/forms). Office keys are returned to the branch and/or transferred to appropriate employee within the branch. If they are no longer required, keys are returned to Police Security Services Division (PSSD) on the ground floor.

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HR6

Exit process checklist continued

Asset Management

2

Important note: To ensure that details on the asset register are accurately maintained an Asset Management Form (Form A1) needs to be completed for each DTF asset that is being returned/transferred. For more details see page 2 of Asset Management Form A1. Asset Management Form A1 is available from Purchasing and Facilities Management or via the Intranet.

Have the following assets been returned/transferred, with a completed Asset Management Form A1? a) Desktop PC

YES

NO

N/A

b) Laptop PC

YES

NO

N/A

c) Home PC

YES

NO

N/A

d) Home printer

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

h) Departmental car

YES

NO

N/A

i) Car park pass

YES

NO

N/A

j) Fuel card

YES

NO

N/A

k) Corporate credit card/Amex

YES

NO

N/A

l) Gold Wing Lounge/Qantas Club Lounge Card

YES

NO

N/A

m) CabCharge card/book

YES

NO

N/A

Desktop PCs and Laptops remain within the branch. Record the new user of the PC on form A1. If it is not known who the new user is then enter the name of the branch in the â&#x20AC;&#x153;Custodian/Ownerâ&#x20AC;? field. The Authorisation must come from the Branch Head.

The Home PC/printer must be transferred back to the branch for use accordingly. If it is no longer required it should be transferred to the Help Desk. The Help Desk can be contacted on 69590 to arrange for the PC/printer to be picked up.

e) Home furniture Any furniture, belonging to the department currently on loan, must be transferred back to the branch for use accordingly. If the furniture is no longer required by the branch then it can be transferred back to the Purchasing and Facilities Unit. Please contact Purchasing and Facilities Management on 63609 to arrange for the furniture to be picked up.

f) Mobile phone Contact must be made with Purchasing and Facilities Management on 63609 to ensure phones are transferred to a new user, accounts are closed accordingly and diversions are managed to the branch requirements. If the phone is no longer required it must be returned to Purchasing and Facilities Management.

g) Other assets Any other asset belonging to the department, eg dictaphones, video recorders, micro recorders and TVs must also be transferred to the appropriate employee/branch. For more information on this contact Purchasing and Facilities Management on 63609.

Have the following temporarily allocated items been returned?

An employee who has been allocated a departmental car as part of their contract must liaise with Human Resources on the return of that car, along with the car park pass and fuel card.

An employee who has been allocated a Corporate Credit Card/Amex and/or Cabcharge must return their card/s to the Finance Officer, Financial Services prior to their departure. Any Golden Wing/Qantas Club Cards should also be returned to Finance. Cabcharge books can be retained by the branch and allocated to the new employee or appropriate officer. They can also be returned to Accounts Payable, Financial Services if they are no longer required.

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HR6

Exit process checklist continued

Records Management

3

Has Objective been assessed and appropriate records transferred accordingly?

YES

NO

N/A

YES

NO

N/A

Does Network access need to be revoked?

YES

NO

N/A

Does Internet access need to be revoked?

YES

NO

N/A

Does E-mail access need to be revoked?

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

In order to maintain the integrity of the records management system, it is essential when an officer leaves that all records, both files and documents be forwarded/ moved to the appropriate officer on Objective. This ensures that the responsibility for that document/file is passed on and that the correct locations can be found on Objective. An employee within your branch will need to make the appropriate movements on Objective. It may be useful for a report to be printed listing which files/documents are currently located with the employee leaving. Records Management staff can assist in the creation of this report. They can be contacted on 62765. It is important that Records Management staff be informed of whom will be handling the work of the employee leaving the department.

Has Objective access been revoked (if applicable)? If an employee has access to Objective, a Objective Access Form will need to be completed advising to delete a user. The form should be returned to Information and Administrative Services Branch for action. The form is available from the Records Management section (62765) or can be accessed via the intranet (Direct link to IAS/ Key Documents/forms).

Information Technology

4

To revoke an employees access to the Network, Internet and Email, the User Access Request/Modification Form must be completed. Forms are available from the Help Desk or via the Intranet (Direct link to IAS/Key Documents/forms).

Does Remote Access Services (RAS) access need to be revoked? To revoke an employee’s RAS access, the User Access Request/Modification Form must be completed and a special note must be made on this on the form, it will not be assumed.

Do Electronic Mailing Lists need to be updated? To update Electronic Mailing Lists, the User Access Request/Modification Form must be completed and a special note must be made on this form, it will not be assumed.

Has electronic data been archived? It is important before an employee leaves the department that both home user data and personalised folders under the branch are either deleted or transferred. Any data on the h: drive will be deleted when an employee leaves. It is the responsibility of the branch to ensure that files stored on \\romulus\data (u: drive) are transferred. Another item that should be archived is the users “.pst” file (outlook storage of emails)

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HR6

Exit process checklist continued

Delegations

5

Is there a need to transfer and/or revise any of the following delegations: a) Financial/Expenditure delegation?

YES

NO

N/A

b) Purchasing delegation?

YES

NO

N/A

c) Contract delegation?

YES

NO

N/A

d) Ministerial delegation (Administered Items)?

YES

NO

N/A

Has advice of these changes been forwarded to Financial Services?

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

YES

NO

N/A

To effect a change to any delegation, a memo must be forwarded to the Financial ccountant, Financial Services stating the reason for the change. Although it is noted that delegations apply to the position, not the person, Financial Services still require notification of the new delegate.

Other issues

6

Have Human Resources (including Payroll) been notified? When an employee leaves the department, Human Resources must be notified in writing in order to adjust relevant pay details. This may be by the completion of a Separation Advice HR15, which is available from Human Resources or via the Intranet (Human Resources/HR Forms), or if an employee is transferring to another government department, then formal advice (ie contract/memo) must be supplied to Human Resources.

Have SuperSA been notified? Please contact the Super SA Member Services area on 1 300 369 315 to obtain an appropriate fact sheet regarding the termination or transfer of an employee’s superannuation scheme.

Has consideration been given to completing the Exit Interview Questionnaire? The Exit Interview Questionnaire (Form HR20) is an optional but valuable exercise, which provides insight into possible improvements within the Department. The questionnaire is available via the Intranet (Direct link to Human Resources/HR forms). Completed questionnaires should be returned to Human Resources.

Have Telesearch and internal phone lists been updated? Changes to Telesearch should be done prior to the employee’s departure. It is the employee’s responsibility to make the changes and submit them. Telesearch can be accessed via the Intranet. Advice should be given to branch contact to make relevant changes to internal phone lists.

Have the details on the Intranet been updated? Any alterations needed to the Intranet, as a result of an employee leaving, should be forwarded to the Online Services Team, Information and Administrative Services on 62181.

Signatures

7

Employee’s signature

Date ____/____/_________

Branch Manager’s signature

Date ____/____/_________

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HR5

This form is used by Human Resources to notify Payroll of changes to your salary.

Additional duties g Needin e nis a g r o o t itional an Add s Dutie nce? Allowa

If a member of your staff is performing additional duties in their normal role, please complete this form for HR

1

Provide employee’s details

2

Choose the allowance criteria and explain the reason for the need for additional duties

3

Sign the form, get Human Resources representative’s signature, and then forward to DAIS payroll

Any questions regarding completion of this form? Call: Human Resources Telephone 08 – 8226 3135

Send the completed form to: DTF Human Resources for approval

Employee Surname

First name

Branch/Section

Employee number

Position title

Classification

1

use Do not you m if this for g into in t are ac rent if d a fe role

/ Position number

Additional Duties Allowance To be paid an allowance which together with the substantive salary equates to classification level*

2

Start date

/

____/____/_________

To be paid a set allowance of ***

End date (inclusive)** ____/____/_________

Original commencement date ____/____/_________

$ _________________ Justification for payment of Additional Duties Allowance

*

Remuneration payable should be at the first step of the relevant classification level where that level is one above the employee’s substantive level. The aggregate continuous period of additional duties should not exceed 12 months. *** Allowances over $6000 must be validated by the Manager, Human Resources. **

DTF approvals

3

Branch Head or Delegate’s signature

Date ____/____/_________

Thank you!

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HR4

This form is used by Human Resources to keep an up-to-date record of all DTF positions.

Changing details or abolishing a position o Need t a change ? n positio Make sure all details are recorded by following these simple steps

Any questions regarding completion of this form? Call:

1

Fill in details of the current position

2

Fill in the changes to the position

3

Fill in Supervisor/Manager details

4

Get the authorised delegateâ&#x20AC;&#x2122;s approval

5

Send the form to Human Resources

Human Resources Telephone 08 â&#x20AC;&#x201C; 8226 3135

Send the completed form to: DTF Human Resources for approval

Current position details

1

Classification

Branch/Section

/ Current position title

Position number

Current occupant (if applicable)

Employee number

Revised position details

2

Classification

Branch/Section

Trainee Scheme

/

or

$ ____________ pw

Revised position title (limited to 30 characters)

Position status

ASCO code

Ongoing Full-time PSM Act *

Level 5 code

Paypoint*

* Payroll codes

Abolish position

Payslip dist*

Admin location

Classification Advice provided? If yes, please attach to this form.

Career group*

Cost unit*

Yes

No

Attached

Supervisor/Manager of the position

3

Name of Supervisor/Manager (REL 1)

Position number

Name of Supervisor/Manager (REL 2)

Position number

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HR4

Changing details of a position continued

Authorised delegate’s approval

4

Delegate’s name

Title

Delegate’s signature

Date ____/____/_________

5

Send the completed form to: Human Resources Department of Treasury and Finance Corporate Services Level 3, 200 Victoria Square Adelaide SA 5000

Thank you!

Office use only HR Administration – Position Administration noted Date ____/____/_________ Payroll noted

Financial Services noted

Date

Date

____/____/_________

____/____/_________

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HR3

This form is used by Human Resources to keep an up-to-date record of all DTF positions and employees.

Creating a new position g Creatin a new n? positio Make sure all details are recorded by following these simple steps

1

Fill in details of the new position

Any questions regarding completion of this form? Call:

2

Fill in Supervisor/Manager details

3

Get the authorised delegateâ&#x20AC;&#x2122;s approval

Human Resources Telephone 08 â&#x20AC;&#x201C; 8226 3135

4

Send the form to Human Resources

Send the completed form to: DTF Human Resources for approval

New position details

1

Trainee Scheme

Classification

Branch/Section

/

or

$ ____________ pw

New position title (limited to 30 characters)

Hours of duty

ASCO code

Position status Ongoing Full-time PSM Act Level 5 code*

per week per fortnight

Paypoint*

Payslip dist*

Admin location

Cost unit*

Career group*

* Payroll codes

Supervisor/Manager of the position

2

Name of Supervisor/Manager (REL 1)

Position number

Name of Supervisor/Manager (REL 2)

Position number

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HR3

Creating a new position continued

Authorised delegate’s approval

3

Delegate’s name

Title

Delegate’s signature

Date ____/____/_________

4

Send the completed form to: Human Resources Department of Treasury and Finance Corporate Services Level 3, 200 Victoria Square Adelaide SA 5000

Thank you!

Office use only HR Administration – Position Administration noted Date ____/____/_________ Payroll noted

Financial Services noted

Date

Date

____/____/_________

____/____/_________

New Position number

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HR2

This form authorises the change of working hours for PSM Act employees. It is also used to change working days, even when the working days are not changing.

Change to

Hours of duty o Need t ur o y e chang g in k r wo ? s r u o h

Please take these four steps to lodge your request

1

Provide your current employment details

2

Detail the requested new hours of duty and sign your request

3

Get your Branch Head’s signature

Send the completed form to:

4

Lodge your request

DTF Human Resources for approval

Any questions regarding completion of this form? Call: Human Resources Telephone 08 – 8226 3135

Employee Surname

First name

Telephone number (work)

Employee number

Branch/Section

Classification

1

(ie. AS04/02)

/ Position title

Position number

Request to change the hours or days of duty

2

Please change my hours of duty as shown in the table at right from

hours per fortnight

to

hours per fortnight

Please change my working days as shown at right.

Total hours* for each working day (excluding lunch period): Week 1

**

Week 2

***

* ** ***

Effective date

SAT

SUN

MON

TUE

WED

THU

FRI

SAT

SUN

MON

TUE

WED

THU

FRI

Hours worked per day cannot exceed 7.5 hours Week 1 is the first week after payday Week 2 is only required for a 14 day roster cycle.

Employee’s signature

Date ____/____/_________

____/____/_________

DTF approvals

3

Branch Head or Delegate’s signature

Date ____/____/_________

Thank you!

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HR1 Employment contract How this to use : form

Applicant to do: This form has already been prefilled.

Applicant to approve these contract details by signing part 4

Any questions? Call your contact person

1

Carefully read and check the contract details on the letter attached

2

Sign both copies at the bottom of the page

3

Return one copy to DTF, and retain the other copy for your own records

Send the completed form to: Your contact person

Your contact personâ&#x20AC;&#x2122;s details

1

Your contact person

Branch

Telephone

Postal address

Suburb

State

Postcode

Your details Surname

First name

2

Position details Paypoint

Classification

Branch/Section

3

/ Position title

Position number

Salary

Next increment date

$ ____________________ pa

____/____/_________

Salary range from $ __________________

Per year Per week

to $ __________________

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HR1

Employment contract continued

Position details (continued)

3

Contract duration Ongoing Temporary

Start date

Position type Full-time Part-time

Hours of duty

End date (if temporary)

______/______/__________

______/______/__________ Start time on first day am pm

per week per fortnight

Workplace address

Special conditions (if applicable)

Kiosk access:

Manager

Employee

Applicantâ&#x20AC;&#x2122;s signature

4

I have read and understood the conditions of the above contract and accept the employment offer I can not accept the employment offer at this time Date

Signature

____/____/_________

5

Reset Form

Keep a copy for your records and send the other one to DTF

Save Form

Print Form

Send a copy to the address listed on page 1 under your contact personâ&#x20AC;&#x2122;s details

Thank you!

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HR1

This form is used by Branch Delegates to formally advise successful applicants.

Employment contract How this to use : form

This form is to be filled out as follows:

DTF prefills all form details, parts A–C (for office use only) & parts 1–3 (to be sent to the applicant) Applicant approves the contract details by signing part 4

1

Forward returned copy to Human Resources

2

Name the contact person on page 1 and fill out contract details on page 2

3

Send 2 copies of the prefilled form to the applicant

Any questions regarding completion of this form? Call: Human Resources Telephone 08 – 8226 3135

Send the completed form to: DTF Human Resources

Applicant to do: 1

Carefully read and check the contract details on the letter attached

2

Return one copy to DTF, and retain the other copy for your own records

3

Sign both copies at the bottom of the page

Applicants details Surname

First name

A Position title

Position advertising Was this position advertised in the notice of Vacancies?

B

YES Vacancy number Links to Letters

NO Advertisement date ____/____/_________

Note: If the position was not advertised in the Notice of Vacancies the contract period can not be longer than 12 months from the date of commencement. An extension that results in the aggregate contract period being greater than 12 months will require the position being advertised in the Notice of Vacancies.

Supervisor/Manager

C

Surname

First name

Useful Links

D

Links to related lettters Ongoing Appointment of an existing PSM Act Employee Ongoing Appointment for a SA Government Employee from another ACT, eg. SAHC, TAFE, Education, Police etc. Ongoing Appointment of application from outside the Public Sector Temporary Appointment – right to further appointment in DTF (ie. currently permanent DTF employee) Temporary Appointment – right to further appointment (ie. in another government agency) Temporary Appointment – no right to further appointment (ie. no permanent status in DTF or other government agency)

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F7

This form is used by DTF Financial Services to pay out unclaimed monies to approved claimants

Application for

unclaimed money

Any questions completing this form? Call:

have Doyou ed im If you uncla with have any monies ? unclaimed DTF

1

Provide details of the owner/s of the unclaimed money

2

Provide agent details, if they are lodging this form on your behalf

funds with the DTF, please fill this form out carefully, following these steps.

3

Provide claim details

4

Sign the declaration in the presence of an # authorised witness

5

Attach required* certified supporting evidence

Unclaimed Monies Section Corporate Services Branch Telephone 08 - 8226 3106

Send the completed form to: Department of Treasury and Finance Unclaimed Monies Section Corporate Services GPO Box 1045 Adelaide SA 5001 (ABN 19 040 349 865)

Owner details â&#x20AC;&#x201C; Owner 1

1

Surname

First name

Current residential address

Current postal address

Date of birth

Postcode

Postcode

Same as above

Tax file number (Unclaimed Superannuation funds only)

____/____/_________ Daytime telephone number

Email address

Owner details â&#x20AC;&#x201C; Owner 2 Surname

First name

Current residential address

Current postal address

Date of birth

Postcode

Postcode

Same as above

Tax file number (Unclaimed Superannuation funds only)

____/____/_________ Daytime telephone number

Email address

If there are more than two claimants, please attach a schedule with details as above.

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F7

Application for

unclaimed money continued

Agent details (if applicable) Ownerâ&#x20AC;&#x2122;s client number (if known)

2 Contact name

Business name

Business address

Postcode

Same as above

Business postal address

Daytime telephone number

Postcode

Email address

Claim details Claim amount

3

$

.

Please note: ALL PAYMENTS of unclaimed money will be made by cheque and posted to the current postal address as advised on this form.

IMPORTANT: Attach supporting evidence to Part 5 of this form. Name of the enterprise or superannuation provider with whom the money was held prior to being unclaimed:

Address (if known)

Declaration/authority

4

I/We do solemnly and sincerely declare the following: 1. I/We declare that I am/we are the owner(s) of the unclaimed money, the subject of this claim. 2. I/We declare the information and contents of this application and information provided in support of this application are, to the best of my/our knowledge, true and correct. 3. I/We acknowledge that under the Oaths Act 1936, penalties will apply for making a false or misleading statement in or in connection with this application. 4. I/We accept if the conditions are not met, I/we will not be entitled to receive a repayment or retain the unclaimed money repaid. 5. I/We declare that the agent identified in Part B is authorised to act on my/our behalf. 6. And I/we make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Oaths Act, 1936.

Owner 1 signature

Owner 2 signature

Date ____/____/_______

Authorised witness signature#

Date ____/____/_______

Authorised witness signature#

Date ____/____/_______

Date ____/____/_______

Authorised witness name

Authorised witness name

Authorised witness address

Authorised witness address

# An authorised witness in South Australia is a Justice of the Peace, a Notary Public, a Proclaimed Manager of a Bank or Credit Union, or a Proclaimed Police Officer.

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F7

Application for

unclaimed money continued

Supporting evidence

5

Have you attached all the supporting evidence requested in the checklist below? Proof of identity (a) must be provided along with either proof of a connection with last known address (b) or proof of a connection to the enterprise that forwarded the unclaimed money to the Department of Treasury and Finance (c). a) Proof of Identity

ATTACHED

This includes a certified copy* of one of the following: drivers licence, passport or birth certificate. Where the owners name has changed from the Department of Treasury and Finance records, attach a certified copy* of the marriage certificate or other documentation evidencing change of name. Please note: If claiming Superannuation you will also need to provide your Tax File Number and date of birth.

b) Proof of a connection with last known address

ATTACHED

This can be a certified copy* of a council rate notice, electricity or gas bill or similar bills or correspondence with the enterprise that forwarded the money to the Department of Treasury and Finance.

c) Proof of a connection to the enterprise that forwarded the unclaimed money to the Department of Treasury and Finance

ATTACHED

A certified copy* of correspondence from the enterprise, statements, share or premium certificates. If evidence of a connection to the enterprise cannot be provided, a formal letter is required from the enterprise certifying claimant is the rightful owner.

Depending on the circumstances of your claim additional supporting evidence may be required as follows: d) Claim lodged for money held in the name of a deceased estate

ATTACHED

A certified copy* of the Will showing the claimant as the beneficiary and rightful owner, together with a certified copy* of the Grant of Probate or Letters of Administration. A certified copy* of the Death Certificate will be required where no Grant or Probate or Letters of Administration is provided.

Some claims may require additional information for it to be considered properly. If this is the case you will be contacted by the Department of Treasury and Finance. e) If an Agent for the owner is claiming

ATTACHED

Where an Agent for the owner is claiming, a copy of the signed agency agreement must be provided.

Certified Copy*: All copies of documentation and the claim form are required to be certified by an authorised witness. An authorised witness in South Australia is a Justice of the Peace, a Notary Public, a Proclaimed Manager of a Bank or Credit Union or a Proclaimed Police Officer.

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F6

This form is used by Financial Services to keep a record of items purchased with Petty cash.

Request for

Petty cash Do ed you ne reash petty c ent? em imburs

To receive cash reimbursement, follow these steps

Any questions completing this form? Call:

1

Fill in your personal details

2

Please provide details of the purchase/s

3

Acquire authorisation from a financial delegate

4

Your signature will be required to indicate that you have received the cash

Finance Officer – Accounts Payable Telephone 08 - 8226 3532

Send the completed form to: Corporate Services Finance Officer – Accounts Payable

Recipient details Surname

First name

1 Branch/Section

NOTE: um Maxim for t amoun sh is a petty c

$50

Details of purchase Description of items

Amount

2

$

Invoices/receipts attached Line

Tax code

GST excl. amount

GST

Total incl. GST

$

$

$

0.00

$

$

$

0.00

$

$

$

0.00

$

$

$

0.00

Authorisation All associated invoices/receipts must be attached

3

Attached

Certified by (print name)

Approved by (print name and title)

Signature

Signature

Date ____/____/_________

Recipients signature (indicates you have received the above amount) Signature

4

Date ____/____/_________

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F5

This form is to be completed and attached to the invoice and credit card acquittal in every instance that entertainment is provided to a SA Government employee or associate that will result in Fringe Benefits Tax being payable.

Entertainment advice (send as attachment with invoice) ou Have y ed id v pro ment to in a rt ente ent overnm a SA G an r o ee employ ? te ia c o ass

This form is a requirement in conjunction with Tax Policy Statement 2 – Tax Exempt Body Entertainment. For Fringe Benefits Tax purposes all entertainment provided to SA Government employees and their associates needs to be reported on by the agency providing the entertainment.

Generally an ‘associate’ for an employee includes their spouse and children. In addition an ‘associate’ for SA Government agencies includes all employees of other SA Government agencies and all employees of SA local government authorities but does not include employees of public authorities of other States or Territories.

Any questions completing this form? Call: Accounts Payable Officer Telephone 08 - 8226 3501

Send the completed form to: Corporate Services Accounts Payable Officer

Persons attending the function Name of Government employee*

Department

1

Number of non SA Government employees attending the function** * **

To be charged to object code 73612 Entertainment – FBT To be charged to object code 73611 Entertainment – General

Applicant’s signature Name

Position title

Signature

Date

2

____/____/_________

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F4

This form is used by DTF Financial Services to manage staff travel expenses and keep a record of all business trips within the department.

Travel application/report Do you o need t el v a r t claim es? s expen

To ensure that all your travel expenses are covered, follow these steps

1

Fill in your employment and account details

2

Please provide trip details and dates

3 – 5 Select the function of this form then follow on to provide details in the indicated section

Any questions completing this form? Call: Finance Officer – Accounts Payable Telephone 08 - 8226 3532

6

Sign the traveller’s declaration

7

Acquire authorisation; enter account and tax code details; attach all necessary receipts, and then forward the form and attachments to Financial Services

Send the completed form to: Corporate Services Finance Officer – Accounts Payable

Traveller’s details Surname

First name

Branch/Section

Employee number

1

Preferred payment method

Electronic Funds Transfer

Cheque

Financial institution and branch (eg. Westpac, Pirie Street)

BSB number

Payable to / account holder

Account number

Please make cheque out to “Pay cash”

Trip details Purpose of travel

Departure date

2

______/______/__________ Return date

Destination

______/______/__________

Function of this form

3

Application for cash advance (upcoming travel) Application for reimbursement of travel expenses (completed travel) Report of travel expenses paid with cash advance (completed travel)

go to Part 4 go to Part 5 go to Part 5

Cash advance request (upcoming travel) Total cash advance

4

Meals/incidentals

74932

(Tax code PFR)

$

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F4

Travel application/report continued

Travel expenses (completed travel)

5

As per Commissioner’s Standard 3.2 – Attachment A/B – Allowances. Link here...

Accommodation expenses Check-in date

Hotel/accommodation location Outside Metropolitan Alice Springs Hobart Perth

Within metropolitan Adelaide Adelaide Brisbane Melbourne Sydney

Check-out date

_____/_____/_________

_____/_____/_________

Nights

Total Receipts attached

$

Meal expenses and incidentals Breakfast (1 Overnight travel Within SA Interstate

Day travel Within SA Interstate

Qty

Day travel Within SA Interstate

Qty

Day travel Within SA Interstate

Qty

Total cost

0.00

$

Lunch (2 Overnight travel Within SA Interstate

Total cost

0.00

$

Dinner (3 Overnight travel Within SA Interstate

Total cost

0.00

$

Incidentals cost

Incidentals (4 Within SA

Interstate

0.00

$

1)

BREAKFAST: Employee necessarily departed from headquarters earlier than 7.00am or returned to, or was absent from, headquarters later than 9.00am. LUNCH: Employee necessarily departed from headquarters earlier than 12.00noon or returned to, or was absent from, headquarters later than 2.00pm. 3) DINNER: Employee necessarily departed from headquarters earlier than 6.00pm or returned to, or was absent from, headquarters later than 6.30pm. 4) INCIDENTALS: Reimbursement may only be made for incidental expenditure for completed days absent from headquarters. Excess amount from one meal can be used towards another meal. 2)

Fuel expenses

km’s

at cents/km

Total $

Kilometres cost

Home/office

$

$

0.00

Up to 16100 km

$

$

0.00

$

0.00

Over 16100 km

$

0.00

Total $

0.00

Total travel expenses

$

0.00

Less cash advance you received for this travel

$

Add allowance not claimed prior to travel, or additional allowance claim

$

Amount

$

0.00

> PAGE

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F4 c

Travel application/report continued

Travellerâ&#x20AC;&#x2122;s declaration Please declare all issues that are relevant to your application/report below.

6

Application for cash advance I accept the advance on the understanding that the money is to be used in connection with business travel expenditure. I will provide a travel report and attach a tax invoice to substantiate my expenditure, within 3 days of my return. My accommodation arrangements have been approved by an immediate supervisor. Application for reimbursement of travel expenses / Report of travel expenses I certify that the expenses for which the above amounts are claimed were actually and necessarily incurred in the performance of my duties, and I attach a tax invoice to substantiate my expenditure. Staff holding a corporate purchase card I have made the travel claim on the understanding that I have not charged / will not charge this travel expenditure to my corporate purchase card.

Signature

Date id To avo g sin proces ase , ple delays er to b m e m e r eceipts r h c atta d. e r quire where you! Thank

____/____/_________

Authorisation

7

Certified by (print name)

Approved by (print name and title)

Signature

Signature

Date ____/____/___________

Tax code GST excl. amount

Account number

GST

Total incl. GST

$

$

$

0.00

$

$

$

0.00

$

$

$

0.00

$

$

$

0.00

$

$

$

0.00

$

$

$

0.00

Accounts Payable use only Cash advance payment method Electronic Funds Transfer Cheque

Amount

Issue date

Cheque number

Received by (print name)

$

Signature

____/____/_________

PAGE

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F3

This form is used by DTF Financial Services to follow-up issued cheques for book-keeping purposes

Request for

Cheque cancellation/reissue Do you o need t r o l e c n ca a e u s is e r ? e u cheq

If you need to cancel or reissue a cheque, please proceed as follows:

1

Select requested action

2

Fill in cheque details

3

Specify reason

4

Get approval from the appropriate financial delegate

5

Any questions completing this form? Call: Accounts Payable Officer Telephone 08 - 8226 3501

Send the completed form to:

Attach the cheque or indemnity form to this request and forward to Financial Services

Corporate Services Accounts Payable Officer

Action required

1

I would like the attached cheque to be Cancelled

Reissued

Cheque details

2

Name of vendor/person the cheque is issued to

Cheque number

Reason

3

Cheque lost/misplaced Purchase cancelled Vendorâ&#x20AC;&#x2122;s name incorrect Vendor changed

Cheque destroyed Amount incorrect Vendorâ&#x20AC;&#x2122;s address incorrect Other, please state reason:

Certified by (print name)

Signature

Authorisation Approved by (print name)

Date

4

____/____/_________ Title

5

Signature

Please attach the relevant cheque

Reset Form

Save Form

Print Form

Attached Return this form to Financial Services (address above)

Thank you!

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F2

This form is for when no invoice is available and payment is required

Request for payment Do you e mak have to t for n e paym ice, or serv goods ve a h â&#x20AC;&#x2122;t n but do ice? an invo

To raise a payment with no invoice please follow these steps

1

Complete vendor details, description and GST inclusive amount for each payment request

Any questions completing this form? Call:

2

Ensure payment is authorised by appropriate financial delegate and original documents are attached

Accounts Payable Officer Telephone 08 - 8226 3501

3

Enter account number and tax code details

Send the completed form to: Corporate Services Accounts Payable Officer

Payment details

1

Vendor

Date of purchase/s ____/____/_________

Description of goods or services

Total incl. GST $ $ $

0.00

$

Total payment

Authorisation details IMPORTANT: All original documentation must be attached.

2

Attached

Certified by (print name)

Approved by (print name and title)

Signature

Signature

Date ____/____/_________

Account details

3

Account number

Tax code GST excl. amount

GST

Total incl. GST

$

$

$

0.00

$

$

$

0.00

$

$

$

0.00

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F1

This form is used by Financial Services Accounts receivable for sending out invoices for all goods and services provided by the DTF.

Request for

Invoice/Adjustment note Do you s ood have g es to ic or serv e? invoic

To raise an invoice or an adjustment note, please follow these steps

1

Select requested action

2

Fill in customer details

Any questions completing this form? Call:

3

Provide invoice details

Accounts Receivable Officer Telephone 08 - 8226 1649

4

Please list all items to be included on the invoice at the back of this form and calculate the totals. Then forward the form to the Accounts Receivable Officer

Send the completed form to: Corporate Services Accounts Receivable Officer

Action required

1

I would like the following document to be raised Invoice; or Adjustment note

Invoice no. adjustment relates to

Customer details Company/organisation

Customer number

Requested by:

Reason

2

Invoice address

Marked to the attention of:

Invoice details Branch/Section

Telephone

3 Invoice title / Adjustment note comments

Delegateâ&#x20AC;&#x2122;s signature

Date ____/____/_________

list Please to s all item ed ic o be inv af le r e ov >

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F1

Request for

Invoice/Adjustment note continued

Items to be invoiced

4

Quantity

Description

Unit cost excl. GST $

Tax code

Revenue line –

Unit cost GST

Total incl. GST $

$

Quantity

Description

0.00

Unit cost excl. GST $

Tax code

Revenue line –

Unit cost GST

Total incl. GST $

$

Quantity

Description

0.00

Unit cost excl. GST $

Tax code

Revenue line –

Unit cost GST

Total incl. GST $

$

Quantity

Description

0.00

Unit cost excl. GST $

Tax code

Revenue line –

Unit cost GST

Total incl. GST $

$

Quantity

Description

0.00

Unit cost excl. GST $

Tax code

Revenue line –

Unit cost GST

Total incl. GST $

$

Invoice Total incl. GST

$

0.00

0.00

Accounts receivable use only Invoice number

Invoice date ____/____/_________

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A4

This form is used to gain access to email, network drives and other privileged areas via the DTF Remote Access Portal.

Application for

Remote Access Portal (RAP) Need to access RAP?

If you’d like to apply for access to DTF RAP, please follow these steps

1

Please provide your details.

Any questions? Call:

2

ICT Service Desk Telephone 08 – 8226 9590

3

List 5 questions and answers of your own choice to be used as your security checklist Indicate your access location/s

4

List your software requirements

5

If you are not a DTF employee, your agency contract holder will need to fill in part 5

ICT Service Desk Level 3 State Administration Centre

Send the completed form to:

6 – 7 Sign the form, get Branch Head’s approval, then forward to Corporate Services Applicant Surname

First name

Initials

1 Telephone number

Branch/Section

User account

Security checklist Question (eg. What is my favourite colour?*)

2

*

Answer (eg. Red*)

Q1

A1

Q2

A2

Q3

A3

Q4

A4

Q5

A5

This allows ICT Services to cross-reference your identity with a series of questions that only you would know.

Access location

3

Please tick the location/s from which the DTF Remote Access Portal is being sought Home PC

Operating System and version (eg. Windows XP Home Edition)

DTF Asset

Asset number

> PAGE

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A4

Application for

Remote Access Portal (RAP) continued

Software requirements

4

Standard applications supplied are Microsoft Office (Excel, Outlook, PowerPoint and Word), Internet Explorer, Adobe Acrobat Reader and Winzip. Non-standard software required* YES NO *

Name of software:

A new software licence may need to be purchased with some software, please check with your ICS consultant.

Third party contractor details

5

When the Applicant is employed by a Third Party, an authorised departmental employee must certify below that the Applicant’s employer is compliant with the information security requirements of the contract under which the Applicant is deployed. Access should not be provided for longer than the duration of the contract. Name of third party employer

Contract number

Contract Expiry ____/____/_________

Name of Authorised Departmental Employee

I certify that the applicant’s employer is compliant with the information security requirements of the contract under which the Applicant is deployed. Authorised Departmental Employee’s signature

Date ____/____/_________

Applicant’s signature

6

I agree that my access authority is limited to that which has been approved by the Access Authorisers whose signatures appear on this form and that I shall comply with the Remote Network Access Policy (COR019), StateNet security policy and Agency security policy, copies of which may be obtained from the ICT Service Desk. Applicant’s signature

Date ____/____/_________

Authorisation Branch Head

Branch/Section

Signature

Date

7

____/____/_________

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A3

This form is used by Corporate Services keep an up-to-date record of all employees that have been granted access to the Treasury Network.

Treasury Network user access , Adding g in y if d mo ting or dele rk o w t a ne user?

If you’d like to edit user access details please follow these steps

1

Please select required action, then move to indicated part to complete relevant details

2 – 3 Please provide user details

Any questions? Call: ICT Service Desk Telephone 08 – 8226 9590

Send the completed form to:

4

New users will need to sign this user access declaration

5

Get a signature from the Branch Head, then forward the form to Corporate Services

ICT Service Desk Level 3 State Administration Centre

Required action Requested by

Add a new user Modify user Delete user

1

go to part 2 go to part 3 go to part 3

Add a new user Surname

First name

Initials

Branch/Section

Previous Government Department (if applicable)

2

Access hours required 7am – 7pm 24 hr 7 days a week

Network Access Group:

Email account required YES NO

Distribution list/s:

Internet access required YES NO Non-standard software required YES NO

Name of software:

go to part 4

Modify/delete user Surname

First name

Initials

3 User ID (existing users only)

Modification required:

NOTE: If deleting a user, all personal data on the H:drive will be deleted, unless otherwise advised. go to part 5

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A3

Treasury Network user access continued

User declaration User Security Agreement

4

In consideration of my being authorised to use the Treasury Network, I agree that unless otherwise directed by the Manager, ICT Service Delivery or Manager, Integrated Security that: 1) I will keep my password confidential. 2) I will not write my password, inform any other person of my password, or of any information in relation to my password. 3) I will use the Treasury Network (and attached servers) according to the policies & procedures relating to Information Technology & Security. 4) I will only access the Treasury Network by means of my own password. 5) If I become aware of any unauthorised use of my password, or of the Treasury Network (and attached servers) then I will immediately notify the Manager, Integrated Security. Staff IT Policy Declaration I declare that: •

I have read and fully understand the contents of the department’s ICT Policies (available from DTF Central), particularly:

Software Usage – COR005

Purchase and use of Computing and Communications Equipment – COR016

Email Usage – COR004

Integrated Security – COR030

Virus Protection – COR006

Internet Usage – COR070

Data Storage – COR003

I will comply with the guidelines as described;

I will indemnify the Government of SA against breach of copyright and any unlawful use of software, and

I will comply with the guidelines for ethical conduct pursuant to the Public Sector Management Act, 1995 and any other existing contractual arrangements or other Act governing an employees conduct.

User Access Security Agreement I hereby agree to access the Internet for work purposes only and abide by the directive issued by the Under Treasurer which can be found on the DTF Intranet. User’s name

User’s signature

Date ____/____/_________

Approval from the Branch Head Name of Branch Head

5 Signature

Date ____/____/_________

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A2a

This form is used by Corporate Services Records Management to keep an up-to-date record of all DTF employees who have been granted access to the Objective database.

Access request for

Treasury Objective (Corporate Services) e Welcom to ive! Object

To gain access to the database please follow these six simple steps

1

Provide your current details and action request

Any questions? Call:

2 3

Select the required folder/s you require access to Please indicate if you require training

Team Leader – Records Management Telephone 08 – 8226 9815

4

Read the Objective Access policy, then sign

Send the completed form to:

5

Get your Branch Manager’s signature

6

Lodge your request

Team Leader – Records Management Corporate Services Level 3, State Administration Centre

Your current details Surname

First name

Initials

Position/Title

Branch/Section

1

Telephone

Network ID

PC asset number

Do you require Objective to be deployed to your PC?

YES

NO

Required action and access period New user Delete user

Modify user go to part 5

Permanent access Temporary access: Start date

____/____/______

End date ____/____/______

Corporate Services Access

2

General (Key contact signature only required)

Corporate Services Branch – all users Secured Area Within

Section Head Name

Signature

Date

(Section Head signature required if selecting from below)

Audit & Risk Management Section

____/____/______

Financial Services Section

____/____/______

Human Resources Section

____/____/______

Integrated Security Section

____/____/______

Senior Management (tick one only –

Branch Head Name

Signature

Date

Branch Head signature required if selecting from below)

General Manager General Manager, PA Senior Management Group Director, Financial Services Director, Information and Communication Technology Services Manager, Administrative Services Manager, Audit and Risk Management Manager, Communication Services Manager, Human Resources Manager, Integrated Security

____/____/______

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A2

Access request for

Treasury Objective continued

Records Management training

3

In order to have access to use Objective, you must have received training from a Records Management staff member, in both the departmental correspondence procedures and step-by-step instructions on how to use Objective. Have you received training from an RM staff member?

YES

NO

The Records Management Unit staff will contact you to arrange a time to train you. You will be provided with a Records Management Handbook and Training handbook when you are trained.

Objective access policy Before you access the databases, you will need to agree to comply with the following:

4

1. Deletion of files and documents is only permitted by staff in Records Management, Corporate Services, or by the Systems Administrator of each database. Exceptions will be allowed on a case by case basis, and will be cleared by the Manager, Administration or the System Administrator. 2. Users must ensure, each time they are away from their computers for an extended period of time that they logout of the system for security reasons. Users should also make use of the password protected screen savers supplied with each computer to ensure their computers are protected. 3. Users must abide by the procedures set out in the Objective Handbook. Copies are available from Records Management, Corporate Services. 4. Users are required to undergo training prior to accessing Objective.

Your signature I have read the above policy and agree to comply with it. Date

Signature

____/____/_________

Your Branch Manager’s approval

5

Branch Manager’s name

Branch/Section

I authorise the above user to have access to the marked Business Classification Scheme folders. Note: Access to DTF Cabinet Submission database automatically assumes physical access to Cabinet Submission files.

I authorise the user modifications as described above. I authorise the deletion of this user. Branch Manager’s signature

Date ____/____/_________

6

Send the completed form to: Team Leader – Records Management Corporate Services Level 3, State Administration Centre

Thank you!

Office use only Actioned by Objective System Administrator

Date ____/____/_________ Date

Signed by IT Group

____/____/_________

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A1

This form is used by Corporate Services to record all asset transactions in order to keep the DTF Asset Management System up to date.

Asset management ing, Acquir ing rr e f trans ing t t e g or n rid of a ? t e s s a

To make an asset transaction please follow these 6 steps

1

Provide asset and current asset owner details

2

Select the required transaction and then go to the indicated part to give details

Any questions? Call: ICT Contractors and Finance Telephone 08 â&#x20AC;&#x201C; 8226 3614

Send the completed form to:

3 â&#x20AC;&#x201C; 5 Please provide transaction details 6

An authorised person must sign the form to acknowledge that the asset has been dispatched/received

7

Please forward the form to Corporate Services

ICT Contractors and Finance Level 3 State Administration Centre

Asset details Asset description (eg. personal computer)

Asset number

1 Manufacturer (eg. Hewlett Packard)

Model (eg. NP6050)

Serial number

Other relevant serial numbers (serial numbers of peripherals as required, eg. monitor)

Name of custodian/owner

Full site address

Branch/Section

(eg. Level 3, State Administration Centre, 200 Victoria Square)

Transaction details

2

Add a new asset Transfer an asset Dispose of an asset

Transaction date

go to part 3 go to part 4

____/____/_________

go to part 5

Form completed by

Date ____/____/_________

Add a new asset

3

Order number (from the purchase order)

Purchase price (excl. GST) $

.

go to part 6

> PAGE

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A1

Asset management continued

Transfer an asset Name of new custodian/owner

Branch/Section

4 New site address

(eg. Level 3, State Administration Centre, 200 Victoria Square)

go to part 6

Dispose of an asset Reason for disposal

5

No longer in working order Out of date Redundant

To be salvaged Lost Stolen

Other:

go to part 6

Authorisation

6

Name of Dispatcher/Recipient*

Branch/Section

Signature

Date ____/____/_________

*

7

In case of transfer or disposal an authorisation from the dispatching person is required. In case of an addition or transfer of an asset, an authorisation from the recipient is required.

Send the completed form to:

Corporate Services use only

ICT Contracts and Finance Level 3 State Administration Centre

Recorded by:

Infra number

Signature

Date

Thank you!

____/____/_________

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423 â&#x20AC;&#x201C; 513 Old Northern Rd, Castle Hill, 2154 (Locked Bag 9001, Castle Hill 1765) Phone: (02) 9899 2288 Fax: (02) 9899 3076 Email: employment@oakhill.nsw.edu.au www.oakhillcollege.com.au

Application for Future Enrolment ENTRY DETAILS Desired Level of Entry

Year

7

8

9

10

11

12

Desired Year of Entry

STUDENT DETAILS Family Name Given Names Date of Birth

/

/

Present School Country of Birth Citizenship Religion Student lives with

Both Parents

Parish Mother

Father

Guardian

Page 1 of 4

A Lasallian learning community touching hearts and inspiring minds.


Oakhill College Application for Future Enrolment

FAMILY DETAILS

Mother/Guardian Family Name Given Names Title (Mrs, Miss, Ms, Mr etc) Country of Birth

Religion

Home Address Suburb or Town

Post Code

Postal address same as home address Postal Address Suburb or Town

Post Code

Phone (Home)

Phone (Work)

Phone (Mobile)

Email

Father/Guardian Family Name Given Names Title (Mrs, Miss, Ms, Mr etc) Country of Birth

Religion

Home address same as the Mother/Guardianâ&#x20AC;&#x2122;s home address Home Address Suburb or Town

Post Code

Postal address same as home address Postal Address Suburb or Town

Post Code

Phone (Home)

Phone (Work)

Phone (Mobile)

Email Page 2 of 4

A Lasallian learning community touching hearts and inspiring minds.


Oakhill College Application for Future Enrolment

PAST SCHOLARS Please provide details of any relations (sibling or parent) who are current or past students of Oakhill College. Name

House

Name

House

NOTES 1.

Registration on the College’s waiting list does not guarantee enrolment. Offers of enrolment will be made at the discretion of the Principal between 9 and 12 months before the year you seek a place for your child.

2.

Registrations will only be accepted for children who are Australian Citizens or Permanent Residents of Australia.

3.

To process this application, a non-refundable registration fee of $100 is payable. This registration will not be processed until this payment is received.

PAYMENT DETAILS Payment can be made by:

Paying by Post

Send a cheque or money order payable to Oakhill College along with this completed form to:

Oakhill College Locked Bag 9001 Castle Hill NSW 1765

Paying by Fax

Complete the credit card authorisation details on page 4 and fax this completed form to:

(02) 9899 3076

Paying Online

Complete the credit card authorisation details on page 4 and click “submit” once you have completed the form to lodge your application.

Please note: Payment must accompany the completed form. For example, if you pay by post then the completed form must also be mailed. Applications not accompanied by payment will NOT be processed

Page 3 of 4

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Oakhill College Application for Future Enrolment

AUTHORISATION FOR PAYMENT BY CREDIT CARD Studentâ&#x20AC;&#x2122;s Name

Card Type

Visa

Mastercard

American Express

Card No Name on Card Expiry Date

/

I authorise Oakhill College to draw my Mastercard/Visa/American Express for the amount of $100. (please check box)

DECLARATION Please check box or sign and date below, before submitting form. I certify that I have read and understood all information documented in this form. Mother I Agree

Father Date

Guardian /

/

Signature

(Sign only if submitting printed form)

For further information contact the College Registrar at registrar@oakhill.nsw.edu.au

SAVE FORM

PRINT FORM

SUBMIT FORM

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423 â&#x20AC;&#x201C; 513 Old Northern Rd, Castle Hill, 2154, (Locked Bag 9001, Castle Hill 1765) Phone: (02) 9899 2288 Fax: (02) 9899 3076 Email: employment@oakhill.nsw.edu.au www.oakhillcollege.com.au

Employment Application â&#x20AC;&#x201C; Teaching Position POSITION APPLIED FOR

PERSONAL DETAILS Family Name Given Names Former Names (if applicable) Title (Mrs, Miss, Ms, Mr etc)

Date of Birth

/

/

Country of Birth Home Address Suburb or Town

Post Code

Postal Address Suburb or Town

Post Code

Phone (Home)

Phone (Work)

Phone (Mobile)

Facsimile

Email

Religion Not all staff members at Oakhill College are Catholic. Every staff member is however employed in accordance with the adherence to the principles and values of the Catholic Church and, as well as being required by conduct and lifestyle to give witness to the mission of the Catholic Church, is expected to actively support the specifically Lasallian ethos of the College. Religion

Parish Page 1 of 6

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Oakhill College Employment Application Form

EDUCATION DETAILS

Secondary Years Attended

School

Qualifications Attained

(eg 1999–2003)

Tertiary Years Attended

Institution

Degree, Diploma or Certificate Conferred

(eg 1999–2003)

Current Teacher Classification (if applicable) (eg 4YT) and Salary Step (eg Step 11)

Institute of Teachers Classification (include accreditation number if applicable)

List any other educational, professional or technical qualifications – including short courses, you have acquired.

Professional Associations List any professional associations of which you are a member.

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Oakhill College Employment Application Form

EDUCATION DETAILS (CONTINUED)

Pastoral Care All staff members at Oakhill College are expected to be involved in the pastoral care initiatives of the College. For teachers this includes care and support of a vertical tutor group within a House structure. Outline any areas of expertise or interest you have in the area of pastoral care.

Co-Curriculum Involvement in the curricula program at Oakhill College is not mandatory but is encouraged and supported by the College. Specify any expertise or interest you may have in the area of co-curriculum.

Community Involvement Describe ways that you have been involved in activities associated with your local community.

Briefly outline why you are seeking a position at Oakhill College.

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Oakhill College Employment Application Form

EMPLOYMENT DETAILS Indicate in order, previous positions held, commencing with the most recent position. (Particulars must be furnished for gaps in periods of unemployment)

Current Employer (if not currently employed go to next section â&#x20AC;&#x201C; Past Employment) Name Address Name of Principal/Supervisor Commencement Date

/

/

Job Title Main Duties and Responsibilities

Past Employment Organisation/Company Address Period of Employment

From

/

/

To

/

/

/

/

To

/

/

/

/

To

/

/

Job Title Reason for Leaving Organisation/Company Address Period of Employment

From

Job Title Reason for Leaving Organisation/Company Address Period of Employment

From

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Oakhill College Employment Application Form

EMPLOYMENT DETAILS (CONTINUED)

Details of Teaching Areas Subjects Taught

Level of Teaching

Do you have qualifications/experience/accreditation in the teaching of Religious Education? If Yes, please provide details.

Number of Years

Yes

No

Referees State the name, occupation and address of three persons to whom reference may be made in regard to character and professional competency. (One of these persons must be a recent employer) Name

1

Job Title or Occupation Address Phone (Work)

Phone (Mobile)

Name

2

Job Title or Occupation Address Phone (Work)

Phone (Mobile)

Name

3

Job Title or Occupation Address Phone (Work)

Phone (Mobile)

I have advised the above referees that they have been included on this application form and they have agreed to discuss my application with a member of the selection panel. (please check box) Page 5 of 6 Reset Form

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Oakhill College Employment Application Form

OTHER It is our aim to continually refine our employment processes. It would be appreciated if you could assist us by completing the information below. Where did you hear about this position? Sydney Morning Herald

Teachers on Net

Other (please provide details below)

DOCUMENTATION â&#x20AC;&#x201C; Please include photocopies or scans of academic transcripts â&#x20AC;&#x201C; Enclose only copies of original documents In line with the Child Protection Legislation (1998), consent to screening procedures is a requirement for all prospective employees of the College. Please check box or sign and date below, before submitting form. I certify that the information on this form is complete and correct in every detail and I understand that deliberate inaccuracies or omissions may result in non-acceptance of this application and/or termination of employment. I Agree

Date

/

Signature

/ (Sign only if submitting printed form)

Please note: Only short-listed applicants will be contacted. Thank you for your interest in seeking employment at Oakhill College. Please return completed Application Form to: The Deputy Principal Oakhill College Locked Bag 9001 Castle Hill NSW 1765 OR Email: employment@oakhill.nsw.edu.au

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423 â&#x20AC;&#x201C; 513 Old Northern Rd, Castle Hill, 2154, (Locked Bag 9001, Castle Hill 1765) Phone: (02) 9899 2288 Fax: (02) 9899 3076 Email: employment@oakhill.nsw.edu.au www.oakhillcollege.com.au

Employment Application â&#x20AC;&#x201C; Support Staff Position applied for

PERSONAL DETAILS Family Name Given Names Former Names (if applicable) Title (Mrs, Miss, Ms, Mr etc)

Date of Birth

/

/

Country of Birth Home Address Suburb or Town

Post Code

Postal Address Suburb or Town

Post Code

Phone (Home)

Phone (Work)

Phone (Mobile)

Facsimile

Email

Religion Not all staff members at Oakhill College are Catholic. Every staff member is however employed in accordance with the adherence to the principles and values of the Catholic Church and, as well as being required by conduct and lifestyle to give witness to the mission of the Catholic Church, is expected to actively support the specifically Lasallian ethos of the College. Religion

Parish Page 1 of 6

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Oakhill College Employment Application Form

EDUCATION DETAILS

Secondary Years Attended

School

Qualifications Attained

(eg 1999–2003)

Tertiary Years Attended

Institution

Degree, Diploma or Certificate Conferred

(eg 1999–2003)

List any other educational, professional or technical qualifications – including short courses, you have acquired.

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Oakhill College Employment Application Form

EDUCATION DETAILS (CONTINUED)

Professional Associations List any professional associations of which you are a member.

Community Involvement Describe ways that you have been involved in activities associated with your local community.

Briefly outline why you are seeking a position at Oakhill College.

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Oakhill College Employment Application Form

EMPLOYMENT DETAILS Indicate in order, previous positions held, commencing with the most recent position. (Particulars must be furnished for gaps in periods of unemployment)

Current Employer (if not currently employed go to next section â&#x20AC;&#x201C; Past Employment) Name Address Name of Principal/Supervisor Commencement Date

/

/

Job Title Main Duties and Responsibilities

Past Employment Organisation/Company Address Period of Employment

From

/

/

To

/

/

/

/

To

/

/

/

/

To

/

/

Job Title Reason for Leaving Organisation/Company Address Period of Employment

From

Job Title Reason for Leaving Organisation/Company Address Period of Employment

From

Job Title Reason for Leaving Page 4 of 6 Reset Form

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Oakhill College Employment Application Form

OTHER PARTICULARS

Referees State the name, occupation and address of three persons to whom reference may be made in regard to character and professional competency. (One of these persons must be a recent employer) 1

Name Job Title or Occupation Address Phone (Work)

Phone (Mobile)

Name

2

Job Title or Occupation Address Phone (Work)

Phone (Mobile)

Name

3

Job Title or Occupation Address Phone (Work)

Phone (Mobile)

I have advised the above referees that they have been included on this application form and they have agreed to discuss my application with a member of the selection panel. (please check box)

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Oakhill College Employment Application Form

DOCUMENTATION â&#x20AC;&#x201C; Please include photocopies or scans of academic transcripts â&#x20AC;&#x201C; Enclose only copies of original documents In line with the Child Protection Legislation (1998), consent to screening procedures is a requirement for all prospective employees of the College. Please check box or sign and date below, before submitting form. I certify that the information on this form is complete and correct in every detail and I understand that deliberate inaccuracies or omissions may result in non-acceptance of this application and/or termination of employment. I Agree

Date

/

Signature

/ (Sign only if submitting printed form)

Please note: Only short-listed applicants will be contacted. Thank you for your interest in seeking employment at Oakhill College. Please return completed Application Form to: The Bursar Oakhill College Locked Bag 9001 Castle Hill NSW 1765 OR Email: employment@oakhill.nsw.edu.au

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423 – 513 Old Northern Rd, Castle Hill, 2154 (Locked Bag 9001, Castle Hill 1765) Phone: (02) 9899 2288 Fax: (02) 9899 3076 Email: uniformshop@oakhill.nsw.edu.au www.oakhillcollege.com.au

Uniform Order Form 2011 STUDENT DETAILS Family Name Given Names

Year Level

Boys Uniform Description

College Blazer

Size Required

Unit Price ($)

Measured to fit

Blazer Button Short Sleeve Shirt

Long Sleeve Shirt

Navy Long Trousers – Boys

Navy Long Trousers – Mens

Belts – Black Leather

Ties

SAVE PAGE

Qty

Total Price ($)

180.00

0

0.00

2.00

0

0.00

12

14

16

18

20

23.00

0

0.00

22

24

26

28

30

24.50

0

0.00

12

14

16

18

20

21.00

0

0.00

22

24

26

28

30

23.00

0

0.00

8

9

10

11

12

50.00

0

0.00

14

15

16

17

18

4

5

6

7

8

50.00

0

0.00

4.25

5.25

6.25

7.25

8.25

4.5

5.5

6.5

7.5

8.5

28

30

32

34

36

15.00

0

0.00

38

40

42

Junior

15.00

0

0.00

Senior

20.00

0

0.00

PRINT PAGE

RESET PAGE

13

Page 1 of 5

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Oakhill College Uniform Order Form 2011

BOYS UNIFORM Description

Size Required

Navy School Jumper (wool/cotton)

Tracksuit (top only)

Tracksuit (pants only)

Unit Price ($)

10

12

14

18

20

24

16

Qty

Total Price ($)

58.00

0

0.00

22

65.00

0

0.00

26

28

72.00

0

0.00

12

14

16

18

20

75.00

0

0.00

22

24

10

12

14

16

18

42.00

0

0.00

20

22

24

SUBTOTAL

0 RESET ORDER FORM

CALCULATE TOTALS

BOYS SPORTS UNIFORM Description

Maroon Sports Shorts

House Sports Polo – Benildus House Sports Polo – La Salle House Sports Polo – Miguel House Sports Polo – Mutien House Sports Polo – Solomon House Sports Polo – Turon

Size Required

Unit Price ($)

10

12

14

16

22

24

26

28

10

12

14

S

M

L

10

12

14

S

M

L

10

12

14

S

M

L

10

12

14

S

M

L

10

12

14

S

M

L

10

12

14

S

M

L

18

20

Qty

Total Price ($)

30.00

0

0.00

34.00

0

0.00

34.00

0

0.00

34.00

0

0.00

34.00

0

0.00

34.00

0

0.00

34.00

0

0.00

XL

XL

XL

XL

XL

XL

Socks – Football Socks

2-8

6-11

11-14

8.00

0

0.00

Socks – Navy Ankle Socks

2-8

6-11

11-14

6.50

0

0.00

Hat – Bucket

S

M

L

XL

16.00

0

0.00

Rain Jacket

XS

S

M

L

70.00

0

0.00

Basketball Warm-up Shirt

S

M

L

XL

26.00

0

0.00

SAVE PAGE

PRINT PAGE

XL

RESET PAGE

XXL

Page 2 of 5

A Lasallian learning community touching hearts and inspiring minds.


Oakhill College Uniform Order Form 2011

Boys Sports Uniform Description

Size Required

Unit Price ($)

Qty

Total Price ($)

Basketball Shorts

S

M

L

XL

35.00

0

0.00

Basketball Singlet

S

M

L

XL

26.00

0

0.00

Boys Swimwear

10

12

14

16

35.00

0

0.00

Rugby Jersey

34

36

38

40

42

70.00

0

0.00

Rugby Shorts

28

30

32

34

36

24.00

0

0.00

38

40

Tennis Shirt

S

M

L

XL

46.00

0

0.00

Soccer Shorts

S

M

L

XL

26.00

0

0.00

House Jersey – Benildus

34

36

38

40

42

60.00

0

0.00

House Jersey – La Salle

34

36

38

40

42

60.00

0

0.00

House Jersey – Miguel

34

36

38

40

42

60.00

0

0.00

House Jersey – Mutien

34

36

38

40

42

60.00

0

0.00

House Jersey – Solomon

34

36

38

40

42

60.00

0

0.00

House Jersey – Turon

34

36

38

40

42

60.00

0

0.00

0

0.00

SUBTOTAL RESET ORDER FORM

CALCULATE TOTALS

Girls Uniform Description

College Blazer

Size Required

Unit Price ($)

Measured to fit

Blazer Button

Qty

Total Price ($)

160.00

0

0.00

2.00

0

0.00

Summer Blouse

12

14

16

18

20

27.00

0

0.00

Winter Blouse

12

14

16

18

20

27.00

0

0.00

20.00

0

0.00

180.00

0

0.00

2.00

0

0.00

67.00

0

0.00

7.50

0

0.00

6.50

0

0.00

0

0.00

Winter Bow Tie Kilt

Measured to fit

Kilt Pin Maroon Jumper

12

14

16

18

Stockings – Ink Navy

S

M

L

Talls

Socks – Light Blue

2-8

20

6-11

SUBTOTAL RESET ORDER FORM

SAVE PAGE

PRINT PAGE

RESET PAGE

CALCULATE TOTALS

Page 3 of 5

A Lasallian learning community touching hearts and inspiring minds.


Oakhill College Uniform Order Form 2011

Other Items Description

Size Required

College Bag – Chiropak

Unit Price ($)

Qty

Total Price ($)

Med

80.00

0

0.00

Lg

85.00

0

0.00

College Bag – Navy Sports Bag

28.00

0

0.00

Calculator – Casio FX 82

30.00

0

0.00

0

0.00

SUBTOTAL RESET ORDER FORM

CALCULATE TOTALS

TOTAL Cost Item

Qty

Total Price ($)

Boys Uniform

0

0.00

Boys Sports Uniform

0

0.00

Girls Uniform

0

0.00

Other Items

0

0.00

TOTAL

0

0.00

Prices are subject to change.

CALCULATE TOTALS

PAYMENT DETAILS Payment can be made by:

Paying Online

Complete the credit card authorisation details on page 5 and click “submit” once you have completed the form to lodge your order.

Paying by Post

Send a cheque or money order payable to Oakhill College along with this completed form to:

Oakhill College Locked Bag 9001 Castle Hill NSW 1765

Paying by Fax

Complete the credit card authorisation details on page 5 and fax this completed form to:

(02) 9899 3076

Please Note: Payment must accompany the completed form. For example, if you pay by post then the completed form must also be mailed. Orders not accompanied by payment will NOT be processed.

SAVE PAGE

PRINT PAGE

RESET PAGE

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Oakhill College Uniform Order Form 2011

AUTHORISATION FOR PAYMENT BY CREDIT CARD Studentâ&#x20AC;&#x2122;s Name

Card Type

Visa

Mastercard

American Express

Card No Name on Card Expiry Date Total Amount

/ $

0.00

I authorise Oakhill College to draw my Mastercard/Visa/American Express for the total amount shown above. (please check box)

Contact You will be emailed when your order is ready for collection. If you do not have regular access to your email account, please provide a telephone number. Please allow one week turn around. Please indicate preferred contact method.

Email Contact Phone No (Sign only if submitting printed form)

Signature Date

/

/

For further information contact the College Uniform Shop at uniformshop@oakhill.nsw.edu.au

SAVE FORM

PRINT FORM

RESET FORM

SUBMIT FORM

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423 – 513 Old Northern Rd, Castle Hill, 2154 (Locked Bag 9001, Castle Hill 1765) Phone: (02) 9899 2288 Fax: (02) 9899 3076 www.oakhillcollege.com.au

Professional Development Application Application Process: 1. Applicant completes Applicant’s Details, Professional Development Information, Classes/Duties to be Covered and Payment Details. Form will be forwarded to Faculty Head. 2. Faculty Head assesses application. If approved, form will be forwarded to Staff Replacement Officer to ensure sufficient staff are available to cover the absence. If so, Applicant will

receive email notification. Application if forwarded to Assistant Principal 3. Assistant Principal assesses application. If approved, form will be forwarded to Accounts Payable and Director of Professional Learning. Applicant will receive email notification. If not, please advise Faculty Head. 4. Applicant is responsible for registering/enrolling for the course/ conference after obtaining approval.

Applicant’s DETAILS Full Name of Applicant Email Address Faculty

please select

Faculty Head’s Email Address

-

Faculty Head please select

Rationale for attending Professional Development Information Conference/ Course Name Organisation/Society/Association (If applicable) Duration

hours or

Starting Date

/

/

day(s) Closing Date for Registration

Course No. applicable) (If

/

/

Cost

Venue Have you attended any other Professional Development course this year?

Yes

No Page 1 of 3

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Oakhill College Professional Development Application

Classes / Duties to be Covered DAY 1: Time

Before School Supervision

Period 1

Period 2

Homeroom

Recess

Period 3

Period 4

Lunch

Period 5

Period 6

Bus Duty

/ Location

DAY 2: Time

Before School Supervision

Period 1

Period 2

Homeroom

Recess

Period 3

Period 4

Lunch

Period 5

Period 6

Bus Duty

/

/

/

Location

ADDITIONAL DAYS

Class

Class

Click this button if the Professional Development course runs for more than 2 days

Page 2 of 3

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Oakhill College Professional Development Application

Payment Details

Payee Name Amount (GST inclusive)

Payment Method: Cheque (Post)

Cheque (Provided to Applicant)

SAVE & SUBMIT FORM

EFT

RESET FORM

Approval – Faculty Head Faculty Head’s Name

please select

/

Date

/

Faculty Head will need to discuss with the applicant the appropriate feedback process following this course. The applicant will give feedback to the College via:

Faculty Meeting

Full Staff Meeting

Written Report in Teaching Portal

No Feedback Required

APPROVED

NOT APPROVED

Approval – Staff replacement officer SR Officer’s Name Date

Natalie Lamey /

/

There are sufficient teaching staff to cover this absence

APPROVED

Yes

No

NOT APPROVED

Approval – Assistant Principal Asst Principal’s Name Date

Keith Murray /

APPROVED

/

NOT APPROVED

Page 3 of 3

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Oakhill College Professional Development Application

Classes / Duties to be Covered DAY 3: Time

Before School Supervision

Period 1

Period 2

Homeroom

Recess

Period 3

Period 4

Lunch

Period 5

Period 6

Bus Duty

/

/

Location

Class

RETURN TO FORM

DAY 4: Time

Before School Supervision

Period 1

Period 2

Homeroom

Recess

Period 3

Period 4

Lunch

Period 5

Period 6

Bus Duty

/ Location

/ Class

RETURN TO FORM

A Lasallian learning community touching hearts and inspiring minds.


HR 10

Government of South Australia

Application for Leave of Absence Use this form to apply for a leave of absence

1

To make sure the details are recorded correctly, follow these steps

1 2 3 4 5 6

Fill in Your Details Fill in Amended Leave Details if Appropriate Fill in Length of Leave Details Fill in the Type of Leave Details Sign Form Send to payroll Team 01 DX 703

YOUR DETAILS NAME

given names

LAST NAME

preferred name

employee no

division

SECTION /BRANCH

work phone no position

2

(

) Full Time

Part Time

amended leave Only fill this section if you are making changes to a previously submitted application for absence of leave

leave type

original dates

3

Recreation Leave

from

/

Sick Leave

/

Carers Leave

to

/

Long Service Leave

/

length of leave length

dates

Working Days

Calendar Days

from

/

/

to

/

/

from

/

/

to

/

/

flexi days Note any flexi days to be taken in conjunction with requested leave

Hours

(inclusive)

Page

1 of 3


HR 10

Application for Leave of Absence

4 TYPE OF LEAVE REcreation leave applying for recreation Leave (rec) do you request payment in advance

Yes

20 clear working days notice is required for prepayment

No

sick leave applying for sick Leave (own illness) (sic)

reason medical certificate Required for absences greater than 3 days

Illness

Injury

Is attached

Is NOT attached

carers leave Carers leave will be taken from sick leave entitlements

applying for family carers leave (FAML) applying for carers leave (CLPC)

Must submit satisfactory evidence of carer responsibilities upon request (Please see HR Guide 174)

long service leave applying for pro rata long service leave payment OPTION A

Yes

Full pay

payment OPTION B

Half pay

part time service LSL balance shown in hours

advance payment

5

No

Full time

Payment over half period

Only receive payment in the first half of your LSL period

Payment over full period

Payment distributed evenly across full LSL period

Second half of LSL will be booked as special leave without pay

Current part time hours

Payment in advance

Average hours over career (Adjusted Rate)

30 clear working days notice is required for prepayment

signature sign here

Save

date

/

/

Print

Page

2 of 3


HR 10

Application for Leave of Absence

recommendation Only required if Manager/Section Head is different to Delegate

name

FIRST NAME

signature

LAST NAME

date

/

/

authorisation by delegate As per Section 9 “Leave” or Section 11 Attendance” I approve this leave application on the basis that the employee has sufficient leave entitlements

name

FIRST NAME

LAST NAME

title

signature

date

/

/

Page

3 of 3


HR 59

Government of South Australia

Application for Special Leave Use this form to apply for special leave

1

To make sure the details are recorded correctly, follow these steps

1 2 3 4 5 6

Fill in Your Details Fill in Amended Leave Details if Appropriate Fill in Length of Leave Details Fill in the Type of Leave Details Sign Form Send to payroll Team 01 DX 703

YOUR DETAILS NAME

given names

LAST NAME

preferred name

employee no

division

SECTION /BRANCH

work phone no position

2

(

) Full Time

Part Time

amended leave Only fill this section if you are making changes to a previously submitted application for absence of leave

leave type

original dates

3

Special Leave

Paid Maternity Leave /Adoption Leave

Special Leave Without Pay

from

/

/

Special Leave With Pay Maternity /Adoption Transition

to

/

/

length of leave length

dates

Working Days

Weeks

from

/

/

to

/

/

from

/

/

to

/

/

flexi days Note any flexi days to be taken in conjunction with requested leave

Hours

(inclusive)

Page

1 of 4


HR 59

Application for Special Leave

4

type of leave special leave with pay special leave with pay for individual needs and responsibilities

Bereavement leave

Birth of partnerâ&#x20AC;&#x2122;s child

Care of a sick child who is a dependant

Special cultural/religious event

Urgent pressing necessity

Volunteers leave

Moving house (please notify DPC of your new address) Other

PLEASE SPECIFY

other special leave with pay

Emergency Service calls

Defence reservist

Training courses for emergency services activity

Blood donors

Jury service

Human resource development

Attendance in court as a witness

Trade union training

Elite athletes

Responsibility as an employee representative

Disability resulting from war service

Partners leave

Travelling time for employees in remote localities Other

PLEASE SPECIFY

purchased leave (48/52)

special leave without pay special leave without pay

Attending court as a witness

Parental leave

Leave to work in another organisation

Accompany a partner to a regional location is SA

Other

PLEASE SPECIFY

type of leave continued on page 3

Page

2 of 4


HR 59

Application for Special Leave

paid maternity leave / adoption leave Applications for maternity leave with pay must be accompanied with a statement from a medical practitioner that includes the expected date of birth of the child. Applications for paid adoption leave must be accompanied by written evidence of when the adoption will occur

option a – full pay – 16 weeks at full pay

PAYMENT METHOD

option b – half pay – 16 weeks at full pay and 16 weeks unpaid option c – half pay – half pay each fortnight paid over 32 weeks SPLIT PAYMENT INTO 2 EQUAL pay periods

EXTRA OPTIONS

Option A

to be paid in accordance with payment

period 1

period 2

/

/

to

/

/

from

/

/

to

/

/

split with partner

partners leave

Option C

from

Partner must submit seperate leave application, accompanied by medical or adoption evidence.

my leave

Option B

PARTNERS NAME

from

/

/

to

/

/

from

/

/

to

/

/

special leave with pay maternity / adoption transition Up to 15 days SLWP over a 4-month period may be given. • Where an employee was employed on a permanent part-time basis prior to the birth/adoption of a child, pro-rata special leave with pay applies) • (Please refer to HR-Guide 173 for further information)

5

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

signature sign here

Save

date

/

/

Print

Page

3 of 4


HR 59

Application for Special Leave

recommendation Only required if Manager/Section Head is different to Delegate

name

FIRST NAME

signature

LAST NAME

date

/

/

/

/

authorisation by delegate As per Section 9 “Leave” or Section 11 Attendance”

name

FIRST NAME

LAST NAME

title

signature

date

Page

4 of 4


HR 7

Government of South Australia

Additional Duties Use this form to approve additional duties allowance

1

To make sure the details are recorded correctly, follow these steps

1 2

Fill in Employee Details Fill in Additional Duties Details

employee DETAILS NAME

GIVEN NAMES

LAST NAME

PREFERRED NAME

employee no substantive classification salary

step

please select

percentage

%

percentage

%

please select

$ 0

.

substantive position title position no division pay point

please select

cost unit

Only complete if additional duties is paid from a different source than the employeeâ&#x20AC;&#x2122;s salary

cost unit

2

additional duties details A

B

Fill A, B or C

To be paid an allowance which together with the substantive salary equates to the

please select

step of the

please select

To be paid a set allowance $

step of the

please select

.

classification level % of the

To be paid an allowance which together equates to

please select C

Refer to the Cost Unit Spreadsheet on the HR Intranet.If cost unit does not exist please contact the HR helpdesk on 8463 5430

classification level

(usually used for executives only)

additional duties details continued on page 2 Page

1 of 2


HR 7

Additional Duties

commencement date

/

/

original commencement date

/

/

/

TO

/

The aggregate period of additional duties should not exceed 12 months

duties & justification of the remuneration level An outline of the duties required in addition to the substantive duties / the total duties are considered to match the work value associated with the relevant remuneration level as described in the classification standards)

completed by

phone number Save

FIRST NAME

(

LAST NAME

)

Print

recommendation Only required if Manager/Section Head is different to Delegate

name

FIRST NAME

signature

LAST NAME

date

/

/

authorisation by delegate As per Section 9 “Leave” or Section 11 Attendance” I approve this leave application on the basis that the employee has sufficient leave entitlements

name

FIRST NAME

LAST NAME

title

date

/

/

signature

date

/

/

noted

p/e

signature

human resources / payroll

Page

2 of 2


HR 5

Government of South Australia

Bank Account Details • This form is to advise which account(s) you would like your pay to be deposited.

Use this form to indicate which account(s) your pay will be deposited.

• Your pay can be credited to any recognised bank, building society or credit union. Up to four separate accounts can be specified. • You can change this instruction at any time by completing a new form. You should not close any bank accounts until you are satisfied that your pay is being correctly credited to your new accounts. • This form must be received by Payroll Services by 5pm on the Tuesday following a pay day to be effective in the next available pay period. • If you have recently joined the Department, a Tax Declaration Form will also be required. • This form can also be used to advise of account name changes (due to marriage, for example). • Payment cannot be made by cheque.

For further information Contact Payroll Services

ph. 8462 1301 (then select 1)

1

To make sure the details are recorded correctly, follow these steps

1 2 3 4 5 6

Fill in Your Details Fill in First Account Details Fill in Second Account Details if Required Fill in Third Account Details if Required Fill in Fourth Account Details if Required Sign Authorisation

YOUR DETAILS NAME

GIVEN NAMES

LAST NAME

PREFERRED NAME

employee no

division

section/branch effective from pay period ending

2

/

/

account one financial institution

AMOUNT

branch

Total Pay

Fixed Amount $

.

bsb number

account number

account name

Page

1 of 2


HR 5

Bank Account Details

3

account two financial institution AMOUNT

branch

Fixed Amount $

.

bsb number account number account name

4

account tHREE financial institution AMOUNT

branch

Fixed Amount $

.

bsb number account number account name

5

account FOUR financial institution AMOUNT

branch

Fixed Amount $

.

bsb number account number account name

6

authorisation This authorisation replaces any existing disbursments and I herby request and authorise that my wage is paid in accordance with this form

sign here

date

/

/

date

/

/

payroll sign here

Save

Print

Page

2 of 2


HR 2

Government of South Australia

Employee Diversity Information

The following information will be placed on your personnel record and may be used for reporting purposes. Where it is used for reporting purposes all identifying details, such as your name and employee number, will be removed so that confidentiality is maintained.

This form is used to gather information about the diversity of our workforce.

1

To make sure the details are recorded correctly, follow these steps

1 2 3 4

Enter Employee Details Fill in Employment Information Fill in Education Information – Completed Qualifications Fill in Education Information – Qualifications in Progress

EMPLOYEE DETAILS NAME

GIVEN NAMES

LAST NAME

PREFERRED NAME

employee no

division

section/branch

/

DATE OF BIRTH

2

/

SEX

Male

Female

employment information 1. What were you doing prior to being appointed to DPC?

02

Employed – in other SA Public Sector agency

06

Student – University

03

Employed – in other State or Commonwealth Public Sector agency

07

Student – TAFE

04

Employed – in the Private Sector

08

Student – Other training organisation

05

Student – Secondary School

09

Other

2. How were you originally recruited into the South Australian Public Sector?

1

General Recruitment Scheme

7

Aboriginal Employment Program

2

Public Service Exam

8

Disability Employment Strategy

3

Graduate Program

A

Australian Job Search

4

Traineeship

G

Gazettal – Board/Committee Member

5

Apprenticeship

T

Temp Agency

6

Advertised Position

V

Vacational Employment

0

Other

EMPLOYMENT INFORMATION continued on page 2 Page

1 of 5


HR 2

Employee Diversity Information

3. Are you currently employed under any of the following employment programs?

GA

Graduate Scheme

IN

Internship

AP

Apprenticeship

DI

Disability Employment Strategy

AB

Aboriginal Employment Strategy

08

None of the above

TA

Traineeship

4. Do you use any of the following flexible working arrangements?

3

01

Purchased Leave

04

Part-time Job Share

02

Flexitime

05

Working from home

03

Compressed Weeks

00

Not using flexible working arrangements

education information – Completed Qualifications 1.

On what date did you complete your highest qualification? • If you have more than one qualification at the same level please indicate the date of completion for the most recent one. • If day and/or month are unknown, use 01 to fill in the blanks. date

/

/

2. What is the level of the highest qualification you have completed?

00

Year 10 or below

05

Associate Diploma

00

Year 11

06

Advanced Diploma

00

Year 12

07

Bachelor/Honours Degree

01

Certificate 1

08

Graduate Certificate

02

Certificate 2

09

Graduate Diploma

03

Certificate 3

10

Masters Degree

04

Certificate 4

11

Doctoral Degree

Other

3.

What is the main field of study of your highest qualification completed? • If you have completed more than one qualification at the same level, please indicate your most recent qualification. • Please enter the 4 digit code from the code list on page 5.

code

4.

What is the name of your highest qualification completed? • If you have completed more than one qualification at the same level, please indicate your most recent qualification.

qualification

Page

2 of 5


HR 2

Employee Diversity Information

4

education information – Qualifications in Progress 1.

Are you currently taking any course of secondary or tertiary study (eg TAFE, University)? • If you have more than one qualification at the same level please indicate the date of completion for the most recent one. • If day and/or month are unknown, use 01 to fill in the blanks. No

Yes

Please skip to question 5

2. What is the level of qualification you are currently studying?

00

Year 10 or below

05

Associate Diploma

00

Year 11

06

Advanced Diploma

00

Year 12

07

Bachelor/Honours Degree

01

Certificate 1

08

Graduate Certificate

02

Certificate 2

09

Graduate Diploma

03

Certificate 3

10

Masters Degree

04

Certificate 4

11

Doctoral Degree

Other 3.

What is the main field of study of your highest qualification completed? • Please enter the 4 digit code from the code list on page 5.

code

4. What is the name of the qualification you are currently studying? qualification

Page

3 of 5


HR 2

Employee Diversity Information

5

cultural information Are you of Aboriginal and/or Torres Strait Islander origin? 1.

• An Aboriginal person is defined as a person who is a descendant of an Indigenous inhabitant of Australia and who identifies as an Aboriginal. • A Torres Strait Islander is one who is a descendant of or a traditional inhabitant of the Torres Strait Islands.

E

No

B

Torres Strait Islander

A

Aboriginal

C

Aboriginal and Torres Strait Islander

Do you have an ongoing disability requiring adaptation of workplace? 2.

Answer Yes if one or more of the following apply to you: • You are restricted in the type of work you can do, or require modified working hours (restricted hours of work, different time schedules or flexible hours of attendance) • You require your employer to provide adaptive equipment, a modified work environment or make other special work related arrangements • You need ongoing assistance or supervision to carry out your duties.

Yes

No

3. What is the main language that you speak at home other than English?

1201

No language other than English

2401

Italian

4202

Arabic

7104

Mandarin

7101

Cantonese

3602

Polish

3503

Croatian

3505

Serbian

1301

German

2201

Greek

Other 4. What are the countries of birth for you and your parents? you

mother

father

Australia

1101

England

2102

Germany

2304

Greece

3207

India

7103

Italy

3104

Malaysia

5230

Netherlands

2308

New Zealand

1201

Other If you were born outside Australia, in which year did you arrive? 5.

• Leave blank if you were born in Australia. • If day and/or month are unknown, use 01 to fill in the blanks. • Must live in Australia for 1 year or more

date

Save

/

/

Print

Page

4 of 5


HR 2

Employee Diversity Information

Please use the table below to assist you when answering ‘Education Information – Completed Qualifications’ question 3 and ‘Education Information – Qualifications in Progress’ question 3. MANAGEMENT & COMMERCE

NATURAL AND PHYSICAL SCIENCES

0801

Accounting

0101

Mathematical Sciences

0803

Business and Management

0103

Physics and Astronomy

0805

Sales and Marketing

0105

Chemical Sciences

0807

Tourism

0107

Earth Sciences

0809

Office Studies

0109

Biological Sciences

0811

Banking, Finance and Related Fields

0199

Other Natural and Physical Sciences

0899

Other Management and Commerce

0301

Manufacturing Engineering and Technology

ENGINEERING AND RELATED TECHNOLOGIES information technology 0201

Computer Science

0303

Process and Resources Engineering

0203

Information Systems

0305

Automotive Engineering and Technology

0299

Other Information Technology

0307

Mechanical and Industrial Engineering & Tech.

0309

Civil Engineering

agriculture & building

0311

Geomatic Engineering

0401

Architecture and Urban Environment

0313

Electrical & Electronic Engineering & Tech.

0403

Building

0315

Aerospace Engineering and Technology

0317

Maritime Engineering and Technology

0399

Other Engineering and Related Technologies

society & culture 0901

Political Science and Policy Studies

0903

Studies in Human Society

0905

Human Welfare Studies and Services

0501

Agriculture

AGRICULTURE, ENVIRONMENTAL STUDIES

0907

Behavioural Science

0503

Horticulture and Viticulture

0909

Law

0505

Forestry Studies

0911

Justice and Law Enforcement

0507

Fisheries Studies

0913

Librarianship, Information Mgmt & Curatorial Studies

0509

Environmental Studies

0915

Language and Literature

0599

Other Agri., Environmental & Related Studies

0917

Philosophy and Religious Studies

0919

Economics and Econometrics

0921

Sport and Recreation

1101

Food and Hospitality

0999

Other Society and Culture

1103

Personal Services

General Education Programmes (inc. Yr 10,11 & 12)

0601

Medical Studies Nursing

FOOD, HOSPITALITY AND PERSONAL SERVICES

MIXED FIELD PROGRAMMES 1201

HEALTH

1203

Social Skills Programmes

0603

1205

Employment Skills Programmes

0605

Pharmacy

1299

Other Mixed Field Programmes

0607

Dental Studies

0609

Optical Science

0611

Veterinary Studies

CREATIVE ARTS 1001

Performing Arts

0613

Public Health

1003

Visual Arts and Crafts

0615

Radiography

1005

Graphic and Design Studies

0617

Rehabilitation Therapies

1007

Communication and Media Studies

0619

Complementary Therapies

1099

Other Creative Arts

0699

Other Health

0701

Teacher Education

0703

Curriculum and Education Studies

0799

Other Education

EDUCATION

OTHER 0002

Not Elsewhere Classified

Page

5 of 5


HR 1

Government of South Australia

Termination of Employment

or Transfer of Employment to Another Agency Use this form to terminate your employment with the Department.

1

To make sure the details are recorded correctly, follow these steps

1 2 3 4

Enter Your Details Fill in Termination Details Fill in Additional Requests Details Read and Sign Declaration

YOUR DETAILS NAME

GIVEN NAMES

LAST NAME

PREFERRED NAME

employee no postal address To ensure any correspondence eg. pay cheque or group certificate can be forwarded without delay.

POSTCODE

position title

POSITION NO

division

2

termination details Termination date is the last day on which you will be at work, OR if you are taking either Recreation or Long Service leave prior to terminating your services, insert the date of the last day of your leave.

/

effective from the close of business

Resignation

/

reason for leaving

Expiration of Temporary Contract Retirement Transfer to another public sector employer Name of government agEncy/department

Ongoing

Other

Temporary

From

/

/

TO

/

/

please specify

Page

1 of 3


HR 1

Termination of Employment

or Transfer of Employment to Another Agency

3

OTHER ENTITLEMENTS I apply for payment of the monetary value of any Recreation Leave to which I am entitled I apply for payment in lieu of Long Service Leave not taken on termination I request transfer of my leave entitlements to my new public sector employer Name of government agEncy/department

Centrelink “Separation Certificate”

4

declaration Employees: 1.

Must continue to maintain after termination of employment the confidentiality of information gained during public employment;

2.

Cannot use any confidential information gained by virtue of their public employment with the intent of securing a benefit for themselves, any person, company or future employer;

3.

Must return all confidential and sensitive documents and any copies of those documents, and any other Government property, in their possession on leaving public employment;

4.

Understand that failure to comply in the way stated above may result in them being liable for legal proceedings, which could include action for damages or injunction, for breach of confidence.

signature

Save

date

/

/

Print

authorisation by delegate Pursuant to Provisions of the Public Sector Act, I note the termination advice and hereby authorise payment of the sum calculated as being the monetary value of: 1.

The number of pro-rata Recreation Leave days

2.

The number of pro-rata or untaken calendar days Long Service Leave due and

3.

Program day off accruals

4.

Final payment will be reduced by relevant flexitime debit, if applicable

Delegation: Section 10 “Resignations, Retirements and Terminations”

delegates name

signature

FIRST NAME

LAST NAME

date

/

/ Page

2 of 3


HR 1

Termination of Employment

or Transfer of Employment to Another Agency

human resources Sent to payroll

/

date

/

payroll services Employeeâ&#x20AC;&#x2122;s leave paid out

Separation Certificate issued

Employee details updated

Terminated on CHRIS

Leave balances transferred to Agency/Department

Flexitime debit checked

prepared by

date

checked by

date

FIRST NAME

/

LAST NAME

/

FIRST NAME

/

LAST NAME

/

Page

3 of 3


DPCICTF001

Government of South Australia

ICT Standards

scanned infra no.

Change/ Exemption Request Form

Use this form to request a change or an exemption from the ICT Standards.

This form is to be used in conjunction with the ICT Standards and ICT Standards Policy which ensures the products, technologies, protocols, methodologies, specifications and other dimensions that comprise the department’s ICT environment are actively managed so that the benefits that Department of the Premier and Cabinet obtains from its investment in information and communication technology (ICT) is maximised.

To make sure the details are recorded correctly, follow these steps

1 2 3 4 5

Enter Requestor Details Fill in Request Type Details Fill in Business & Technical Context Details Obtain Business Unit Director’s Endorsement Obtain Director’s ICT Strategy’s Approval

1 REQUESTOR NAME

FIRST NAME

LAST NAME

JOB TITLE DIVISION

SECTION / BRANCH TELEPHONE MOBILE

E-MAIL

REQUESTED DATE

2 REQUEST TYPE CHANGE TO ICT STANDARDS

EXEMPTION FROM ICT STANDARDS

3 BUSINESS & TECHNICAL CONTEXT Describe the required change or exemption from the ICT Standards

Describe the business need for the proposed change or exemption

Page

1 of 2


DPCICTF001

ICT Standards

Change/ Exemption Request Form

Identify any existing alternatives to the change or exemption and why these will not meet the requirements

Describe how any potential risks associated with this change or exemption will be managed

4 BUSINESS UNIT DIRECTOR’S ENDORSEMENT I have read and understood all of the details in the ICT Standards Change / Exemption request form and I support the business need and endorse this request

NAME FIRST NAME

LAST NAME

TITLE

SIGNATURE

DATE

5 DIRECTOR ICT STRATEGY’S APPROVAL APPROVAL STATUS

APPROVED

CONDITIONALLY APPROVED

REJECTED

COMMENTS

SIGNATURE

DATE

6 QUESTIONS AND FORWARDING ADDRESS For any further enquiries, please call ICT Strategy on 846 35639 (35639 internal) and upon completion of the form, please forward to ICT Strategy, Level 12, State Administration Centre. (ictpolicy@dpc.sa.gov.au or fax 8226 9421)

Page

2 of 2


DPCICTF002

Government of South Australia

Network User Access

scanned infra no.

Request Form Use this form to add, modify or delete a network user.

To make sure the details are recorded correctly, follow these steps

1 2 – 3 4 5

Please select required action, then move to indicated section to complete relevant details Please provide user details Obtain User Access Agreement Obtain Business Unit Director’s Approval

1 REQUIRED ACTION REQUESTED BY FIRST NAME

TELEPHONE

(

ADD A NEW USER

LAST NAME

) go to part 2

MODIFY USER

go to part 3

DELETE USER

go to part 3

2 ADD A NEW USER NAME

FIRST NAME

LAST NAME

TELEPHONE

DIVISION

BRANCH/SECTION PREVIOUS GOVERNMENT DEPARTMENT (IF APPLICABLE) EMAIL ACCOUNT REQUIRED

NO

YES

Permanent

Temporary

SAME AS USER

start date

end date

transfer sagems mail box from dept. (IF APPLICABLE)

Page

1 of 2


DPCICTF002

Network User Access Request Form

3 MODIFY/DELETE USER NAME

FIRST NAME

LAST NAME

NOTE: If deleting a user, all personal data on the H:drive will be deleted, unless otherwise advised. go to part 5

USER ID (existing users only)

MOVE EMAIL ACCOUNT

MODIFICATION REQUIRED:

4

INITIALS

YES

NO

USER ACCESS AGREEMENT User Access Agreement I have read and understood the DPC User Access Policy and agree to abide by all conditions relating to my network user access. I agree that I will: • Keep my DPC network password confidential • Not utilise any other user’s password to access the DPC network • Alert the Director ICT Strategy to any unauthorised use of the DPC network

NAME

FIRST NAME

LAST NAME

SIGNATURE

DATE

5 BUSINESS UNIT DIRECTOR’S APPROVAL APPROVAL STATUS

APPROVED

REJECTED

COMMENTS

NAME

FIRST NAME

LAST NAME

SIGNATURE

DATE

6 QUESTIONS AND FORWARDING ADDRESS For any further enquiries, please call ICT Strategy on 822 69590 (69590 internal) and upon completion of the form, please forward to the DTF Service Desk, Level 3, State Administration Centre or email to servicedesk@sa.gov.au

Page

2 of 2


DPCICTF003

Government of South Australia

Smartphone and Tablet

scanned

Request Form Use this form to request a Smartphone or Tablet service within the DPC ICT environment.

infra no.

This form is to be used in conjunction with the Smartphone, Mobile Phone and Tablet Guideline and Smartphone and Tablet Policy to demonstrate the requirement for mobility services for a user within the Department of the Premier and Cabinet ICT environment. The acquisition of mobility services must be approved by the relevant Executive Director prior to being submitted to the Director ICT Strategy for processing.

To make sure the details are recorded correctly, follow these steps

1 2 3 4 5 6

Enter Requestor Details Fill in Business Context Details Fill in Technical Information Fill in Financial Information Fill in Applicant’s Declaration Obtain Executive Director’s Approval

1 REQUESTOR NAME FIRST NAME

LAST NAME

JOB TITLE

DIVISION

SECTION / BRANCH TELEPHONE

MOBILE

E-MAIL

2

REQUESTED DATE

BUSINESS CONTEXT Describe the business need and expected benefits of having mobility

3

TECHNICAL INFORMATION Which device do you want to purchase?

Which Mobile Data Carriage Service Plan will you select?

Page

1 of 2


DPCICTF003

Smartphone and Tablet Request Form

4 FINANCIAL INFORMATION Device purchase price

$

Mobile Data Carriage Service Plan charge (per month)

$

SAGEMS Mobility Service charge (per month)

$

Shared Services support charge per month (if applicable)

$

Business Unit Cost Centre

5

-

-

Approximate annual charges

$

-

APPLICANT’S DECLARATION I have read and understood the Smartphone and Tablet Policy and agree to abide by the policy provisions contained therein.

SIGNATURE

DATE

6 EXECUTIVE DIRECTOR’S APPROVAL APPROVAL STATUS

APPROVED

CONDITIONALLY APPROVED

REJECTED

I support the business requirements identified and therefore endorse this request, and acknowledge that all relevant costs arising will be met from existing budgets.

NAME

FIRST NAME

LAST NAME

JOB TITLE SIGNATURE

DATE

7 QUESTIONS AND FORWARDING ADDRESS For any further enquiries, please call ICT Strategy on 846 35639 (35639 internal) and upon completion of the form, please forward to ICT Strategy, Level 12, State Administration Centre or fax to 8226 9421.

Page

2 of 2


DPCICTF004

Government of South Australia

Local Admin Rights

scanned infra no.

Request Form

Use this form to apply for local admin rights.

This form is to be used in conjunction with the Managed Operating Environment (MOE) Policy which is intended to ensure that all staff are provided with a stable, supportable, secure and effective Information and Communication Technology (ICT) platform to support the department’s business activities. The ability to make environment and system modifications, including the installation of software, changes to backgrounds and screen savers etc., is managed through admin rights. In some cases local admin rights may need to be granted to facilitate business requirements, however these changes must be carefully managed to avoid subjecting the ICT environment to unnecessary risk.

To make sure the details are recorded correctly, follow these steps

1

1 2 3 4 5

Enter Requestor Details Fill in Business & Technical Context Details Fill in Applicant’s Declaration Obtain Business Unit Director’s Endorsement Obtain Director ICT Strategy’s Approval

REQUESTOR NAME

FIRST NAME

LAST NAME

JOB TITLE

DIVISION

SECTION / BRANCH

TELEPHONE

MOBILE

E-MAIL

2

REQUESTED DATE

BUSINESS & TECHNICAL CONTEXT Describe the business need and expected benefit of having local admin rights

Page

1 of 2


DPCICTF004

Local Admin Rights Request Form

3 APPLICANT’S DECLARATION I have read and understood the Managed Operating Environment (MOE) Policy and agree to abide by the terms contained therein. I understand that all modifications to the MOE must be approved by the Change Management Committee (CMC) in accordance with the ICT Standards Policy. I understand that once granted local admin rights, I must not make significant or material modifications to the MOE and cannot, under any circumstances, attempt to modify or circumvent anti–virus and threat management software, or other security control measures. I understand that only approved and licensed software can be installed on ICT client devices and that in the event that a fault is reported on an ICT client device that has been modified, it is expected that reasonable steps to resolve the fault will be taken by the service provider, however the event that such actions are unsuccessful, the MOE will be reinstated.

SIGNATURE

DATE

4 BUSINESS UNIT DIRECTOR’S ENDORSEMENT I have read and understood the details of the local admin rights request form and I support the business need and endorse this request.

NAME

FIRST NAME

LAST NAME

JOB TITLE

SIGNATURE

DATE

5 DIRECTOR ICT STRATEGY’S APPROVAL APPROVAL STATUS

APPROVED

CONDITIONALLY APPROVED

REJECTED

COMMENTS

SIGNATURE

DATE

6 QUESTIONS AND FORWARDING ADDRESS For any further enquiries, please call ICT Strategy on 846 35639 (35639 internal) and upon completion of the form, please forward to ICT Strategy, Level 12, State Administration Centre or fax to 8226 9421.

Page

2 of 2


DPCICTF005

Government of South Australia

Remote Access

scanned infra no.

Request Form

This form is to be used in conjunction with the Remote Access Policy and the Remote Access Guideline to demonstrate the requirement for remote access services for a user within the Department of the Premier and Cabinet ICT environment.

Use this form to apply for remote access.

The provision of remote access services must be approved by the relevant Director prior to being submitted to the Director ICT Strategy for processing.

To make sure the details are recorded correctly, follow these steps and refer to Smartphone and Mobile Phone Guideline if more information is required

1 2 3 4 5 6

Enter Applicant Details Fill in Business Context Details Fill in Service Required Fill in Applicant’s Declaration Obtain Director’s Endorsement Obtain Director’s ICT Strategy’s Approval

1 APPLICANT NAME FIRST NAME

LAST NAME

JOB TITLE DIVISION

SECTION / BRANCH

TELEPHONE MOBILE

E-MAIL

2 BUSINESS CONTEXT Describe the business need and benefits of having remote access

Describe access requirements (eg calendar, email, contacts, applications)

Page

1 of 2


DPCICTF005

Remote Access Request Form

3 SERVICE REQUIRED citrix

outlook web access (OWA)

HARD ToKEN

SOFT ToKEN

VPN

4 APPLICANT’S DECLARATION I have read and understood the details of the Remote Access Policy and I agree to comply with the conditions of the policy as stated.

SIGNATURE

DATE

5 DIRECTOR’S ENDORSEMENT I support the business requirements identified and therefore endorse this request, and I acknowledge that all relevant costs arising will be met from existing budgets.

NAME

FIRST NAME

LAST NAME

JOB TITLE

SIGNATURE

DATE

6 DIRECTOR ICT STRATEGY’S APPROVAL APPROVAL STATUS

APPROVED

CONDITIONALLY APPROVED

REJECTED

COMMENTS

SIGNATURE

DATE

7 QUESTIONS AND FORWARDING ADDRESS For any further enquiries, please call ICT Strategy on 846 35639 (35639 internal) and upon completion of the form, please forward to ICT Strategy, Level 16, State Administration Centre or fax to 8226 9421.

Page

2 of 2


DPCICTF008

Government of South Australia

Asset Management Use this form to add an asset, transfer an asset or dispose of an asset

1

scanned infra no.

This form is to be used by ICT Strategy to record all asset transactions in order to keep the DPC Asset Management System up to date.

To make sure the details are recorded correctly, follow these steps

1 2 3â&#x20AC;&#x201C;4 5

Provide asset and current asset owner details Select the required transaction and then go to the indicated part to give details Please provide transaction details An authorised person must sign the form to acknowledge that the asset has been dispatched/received

transaction details DATE

form completed by

Add an asset

go to parts 2 & 5

dispose of an asset

transfer an asset

go to parts 3 & 5

go to parts 4 & 5

2 asset details asset description (eg. PC Desktop, PC Notebook)

ASSET NUMBER MODEL

SERIAL NUMBER OTHER RELEVANT INFORMATION (activations codes, mobile phone number, for software â&#x20AC;&#x201C; PC asset number)

name of custodian/owner

FIRST NAME

LAST NAME

DIVISION Branch/section full site address (eg. Level 3, State Administration Centre, 200 Victoria Square)

Page

1 of 2


DPCICTF008

Asset Management

3 TRANSFER AN ASSET NAME OF NEW CUSTODIAN/OWNER

FIRST NAME

LAST NAME

BRANCH/SECTION NEW site address

go to part 5

(eg. Level 3, State Administration Centre, 200 Victoria Square)

4

DISPOSE OF AN ASSET REASON FOR DISPOSAL

TO BE SALVAGED

LOST

STOLEN

OTHER/COMMENTS

5 AUTHORISATION NAME OF DISPATCHER OR PREVIOUS OWNER

FIRST NAME

LAST NAME

BRANCH/SECTION

SIGNATURE NAME OF RECIPIENT OR OWNER

DATE

FIRST NAME

LAST NAME

BRANCH/SECTION

SIGNATURE

DATE

6 QUESTIONS AND FORWARDING ADDRESS For any further enquiries, please call ICT Strategy on 846 35639 (35639 internal) and upon completion of the form, please forward to ICT Strategy, Level 12, State Administration Centre, or fax to 8226 9421.

Page

2 of 2


DPCICTF011

Government of South Australia

Dpc Wlan Access Soe & AUTH

scanned infra no.

Request Form Use this form to apply for wireless access.

This form is to be used in conjunction with the Wireless Access Policy and Guidelines. The provision of wireless access services must be approved, in accordance with the guidelines, prior to access being granted.

To make sure the details are recorded correctly, follow these steps

1 2 3 4 5

Enter Requestor Details Fill in Business Context Details Complete Relevant Type of Access Section Sign Declaration Obtain Relevant Approval

1 REQUESTOR NAME

FIRST NAME

LAST NAME

JOB TITLE

DIVISION SECTION / BRANCH TELEPHONE

(

)

E-MAIL

MOBILE

REQUESTED DATE

/

/

2 BUSINESS CONTEXT Describe the business need for the wireless access service

Page

1 of 2


DPCICTF011

Dpc Wlan Access Soe & AUTH Request Form

3 TYPE OF ACCESS DPC-SOE Full network access for equipment with an installed Managed Operating Environment

DPC-AUTH For DPC Authorised users. Access to Internet and approved SA Government resources

REQUIRED

IF TEMPORARY, ACCESS REQUIRED UNTIL

Asset NO

REQUIRED

/

/

/

/

USER ID

IF TEMPORARY, ACCESS REQUIRED UNTIL

USER ID

LIST DEVICES TO BE USED All devices must comply with the security recommendations specified in the Wireless Assess Guideline

4

APPLICANTâ&#x20AC;&#x2122;S DECLARATION I have read and understood the details of the Department of the Premier and Cabinet Wireless Access Policy and Guideline and I agree to comply with the conditions of the policy as stated. I understand that, to ensure compliance with policy or to investigate security related incidents, any device used to connect to the DPC wireless network may be inspected by a person given authority to do so by the Director, ICT Strategy and that access may be withdrawn at any time.

SIGNATURE

DATE

/

/

5 APPROVAL APPROVAL STATUS

APPROVED

CONDITIONALLY APPROVED

REJECTED

COMMENTS

APPROVED BY

POSITION

SIGNATURE

DATE

/

/

6 QUESTIONS AND FORWARDING ADDRESS For any further enquiries, please call ICT Strategy on 8226 2265 (62265 internal) and upon completion of the form, please forward to ICT Strategy, Level 16, State Administration Centre or fax to 8226 9421.

Page

2 of 2


DPCICTF009

Government of South Australia

ICT Equipment

scanned infra no.

Request Form

This form is to seek formal approval to purchase ICT equipment listed in DPC’s ICT Equipment Standards.

Use this form to request the purchase of ICT equipment.

The acquisition of ICT equipment must be approved by the relevant Business Unit Manager before being submitted with a purchase order to ICT Strategy.

To make sure the details are recorded correctly, follow these steps

1

1 2 3 4 5

Enter Requestor Details Fill in Business Context Details Provide details of the phone you want Get your Manager’s approval Forward with completed Purchase Requisition to your relevant service provider

REQUESTOR NAME FIRST NAME

LAST NAME

JOB TITLE SECTION / BRANCH

DIVISION TELEPHONE

(

)

/

REQUESTED DATE

E-MAIL

2

MOBILE

/

BUSINESS CONTEXT Describe the business need for purchasing ICT equipment

3

ICT EQUIPMENT DETAILS What do you want to purchase?

Desktop PC

Software

See the ICT Equipment Standards on the DPC intranet for available equipment.

Notebook PC

Other

NOTE: Smartphones and Tablets must be acquired using the Smartphone / Tablet Request Form

Mobile Phone

Provide detail (model, version, etc)

Page

1 of 2


DPCICTF009

ICT Equipment Request Form

4

APPLICANT’S DECLARATION I have read and understood the details of the Department of the Premier and Cabinet ICT Equipment policy and I agree to comply with the conditions of the policy as stated.

SIGNATURE

5

DATE

/

/

/

/

BUSINESS UNIT MANAGER’S ENDORSEMENT I support the business need and endorse this request.

NAME

FIRST NAME

LAST NAME

JOB TITLE

SIGNATURE

6

BUSINESS UNIT Cost Centre -

7

DATE

-

-

QUESTIONS AND FOWARDING ADDRESS For any further enquiries, please call ICT Strategy on 8463 3227 (33227 internal) and upon completion of the form, please forward, with a completed Purchase Requisition, to ICT Strategy, Level 12, State Administration Centre.

Page

2 of 2


DPCICTF007

Government of South Australia

Change

scanned

Request Form

infra no.

This form is to be used to request a change to the DPC ICT environment.

Use this form to request a change within the DPC ICT environment.

To make sure the details are recorded correctly, follow these steps

1 2 3 4 5 6 7

Enter Requestor Details Fill in Change Classification Details Fill in Section 1 – Minor change planning Fill in Section 2 – Significant change planning Fill in Section 3 – Major change planning Obtain Business Unit Director’s endorsement Obtain Director ICT Strategy’s approval

1 REQUESTOR NAME FIRST NAME

LAST NAME

JOB TITLE

DIVISION

SECTION / BRANCH

please select

TELEPHONE

MOBILE

E-MAIL

2

REQUESTED DATE

Change classification Minor change

0 – 10 Users Significant change

> Complete section A

> Complete sections A & B

10 – 50 Users Major change

More than 50 Users Save Form

> Complete sections A, B & C

Reset Form

Page

1 of 4


Change

Request Form

3

DPCICTF007

Section A â&#x20AC;&#x201C; Minor change planning Description Describe the change required and the reason for the change

Benefits Describe the benefits expected from the proposed change

4

Section B â&#x20AC;&#x201C; Significant change planning Alternatives Identify any existing alternatives to the change and why these will not meet the requirement

Risks Describe how any potential risks associated with this change will be managed

Save Form

Reset Form

Page

2 of 4


Change

Request Form

5

DPCICTF007

Section C â&#x20AC;&#x201C; Major change planning Schedule Indicate the expected outage to implement the change (including dates and times) and basic tasks that will be undertaken

Communication Describe the process for communicating both the outage and the change to the users affected

Test Detail tests that will be undertaken to verify the success of the change

Backout Describe the backout plan should problems arise

Save Form

Reset Form

Page

3 of 4


DPCICTF007

Change

Request Form

6

Business Unit Director’s endorsement NAME FIRST NAME

LAST NAME

JOB TITLE

signature

date

7

Director ICT Strategy’s approval APPROVAL STATUS

APPROVED

CONDITIONALLY APPROVED

REJECTED

comments

signature

date

Save Form

Reset Form

Print & Sign Form

Page

4 of 4


Home Insurance Profile Questionnaireâ&#x20AC;Ś Help us to save you money off your premium! Our request Please take this opportunity to complete this questionnaire as it may help to lower the premium cost of your insurance or alter our policy recommendation to you.

your Details First name

Initial

Family name

Date of Birth /

/ Are you self-employed?

Occupation

Yes Daytime phone number

No

Mobile phone number

Email address

Our broking service As your insurance broker, we review your policies each year prior to renewal to ensure that you get the benefit of policy improvements and price advantages which may be available. Insurance companies have individual underwriting criteria and by having up-to-date information about your current circumstances we can select and recommend the best policies for your needs.

(If the property is jointly owned, complete the details for the second owner) 2nd Owner First name Initial Family name

Date of Birth /

/

Occupation

Are you self-employed? Yes

No

Mobile phone number

Daytime phone number

Email address

property details Mortgage

Name of financial institution

Yes

No

Year Built

If built prior to 1980, has it been rewired? Yes

No

If so, what year?

Do you operate a business from the property? Yes

Is the property a farm or acreage? Yes

Home Type

Home Construction

No

No

Roof

Owner occupied

Double Brick

Cement Tiles

Tenant

Brick Veneer

Steel, eg Colourbond

Landlord

Timber/Weatherboard

Slate

Holiday Home

Fibro Asbestos Cement

Terra cotta tiles

Unoccupied

Stone / Sandstone

Other

RESET

SAVE

PRINT


Our aim

Property Details continued

Our goal is to recommend for your consideration the best value policy we can arrange with a secure and reliable insurer.

Electrical safety switch fitted Yes No Smoke alarm fitted Yes

We also aim to provide you with exceptional personal service because we treat your insurance like our own when we recommend a policy to you.

No

Flood Risk Do you require cover due to flooding from a watercourse, dam or reservoir?

Deadlocks on all external doors Key operated window locks or grills on all external windows

Yes

Local alarm

No

If Yes, any previous flood damage?

Monitored alarm

Yes

No

Distance to nearest possible flooding source? Kilometres

Building and Contents Valuation Guide

Please refer to our website to calculate your correct values www.donnellys.com.au

Please return this form to enable us to provide you with the best insurance recommendation. Mail – Free Post No postage stamp is required within Australia. Use your own envelope and mark it as follows: Donnelly Insurance Brokers Pty Ltd Reply Paid 1833 ADELAIDE SA 5001

replacement cost update Please update my sums insured to the revised amounts shown below and invoice me for the extra premium payable. Replacement cost update: Building $

Contents ,

$

No change ,

Your signature(s) Your Signature

2nd Owner’s signature

Date

/

/

Date

Fax (08) 8236 7700 (be sure to include all pages) Email You can scan and email to insure#@donnellys.com.au Online This form can also be completed online. Go to www.donnellys.com.au and select “Home Insurance“.

office use Policy Number

Client Reference Code

RESET

SAVE

PRINT

SUBMIT

/

/


Car Insurance Profile Questionnaireâ&#x20AC;Ś Help us to save you money off your premium! Our request Please take this opportunity to complete this questionnaire as it may help to lower the premium cost of your insurance or alter our policy recommendation to you.

your Details First name

Initial

Family name

Date of Birth /

/ Are you self-employed?

Occupation

Yes Daytime phone number

No

Mobile phone number

Email address

Our broking service As your insurance broker, we review your policies each year prior to renewal to ensure that you get the benefit of policy improvements and price advantages which may be available. Insurance companies have individual underwriting criteria and by having up-to-date information about your current circumstances we can select and recommend the best policies for your needs.

(If the vehicle is jointly owned, complete the details for the second owner) 2nd Owner First name Initial Family name

Date of Birth /

/

Occupation

Are you self-employed? Yes

No

Mobile phone number

Daytime phone number

Email address

vehicle details Is the vehicle under finance? Name of financial institution Yes

No

Vehicle Use

Vehicle Security

Private

Alarm & Immobiliser

Business

Alarm only

Immobiliser only Where is the vehicle parked at night? Suburb / Town

Post Code

RESET

SAVE

PRINT

Garage

Driveway

Carport

Street


Our aim Our goal is to recommend for your consideration the best value policy we can arrange with a secure and reliable insurer. We also aim to provide you with exceptional personal service because we treat your insurance like our own when we recommend a policy to you.

Nominated Drivers Main Driver (1) First name

Family name

Gender

Usage

Male

Female

%

Are you the vehicle owner? Yes

Yes

Family name

Gender

Usage Female

Yes

Do you own another vehicle? Yes

Gender

Usage Female

Mail – Free Post No postage stamp is required within Australia. Use your own envelope and mark it as follows: Donnelly Insurance Brokers Pty Ltd Reply Paid 1833 ADELAIDE SA 5001 Fax (08) 8236 7700 (be sure to include all pages) Email You can scan and email to insure#@donnellys.com.au Online This form can also be completed online. Go to www.donnellys.com.au and select “Car Insurance“.

/

Yes

Family name

Gender

Usage Female

Year driving licence obtained

Birth Date

%

Are you the vehicle owner?

/

Do you own another vehicle?

No

/

No

Other Driver (4) First name

Yes

Birth Date

Do you own another vehicle?

No

Male

Year driving licence obtained

%

Are you the vehicle owner?

/

No

Family name

Yes

Birth Date /

Other Driver (3) First name

Male

Year driving licence obtained

%

No

/

No

Other Driver (2) First name

Are you the vehicle owner?

Please return this form to enable us to provide you with the best insurance recommendation.

/

Do you own another vehicle?

No

Male

Birth Date

Yes

/

Year driving licence obtained

No

Your signature(s) Your Signature

2nd Owner’s signature

Date

/

/

Date

office use Policy Number

Client Reference Code

RESET

SAVE

PRINT

SUBMIT

/

/


Business Client Profile Questionnaireâ&#x20AC;Ś Help us to save you money off your premium! Our request Please take this opportunity to complete this questionnaire as it may help to lower the premium cost of your insurance or alter our policy recommendation to you.

YOUR business DETAILS Official name of business

Trading name of business (if applicable)

Type of business structure

ABN

Description of the businessâ&#x20AC;&#x2122; activity

Company Sole proprietorship Partnership Names of owners and/or interested parties

Our broking service As your insurance broker, we review your policies each year prior to renewal to ensure that you get the benefit of policy improvements and price advantages which may be available. Insurance companies have individual underwriting criteria and by having up-to-date information about your current circumstances we can select and recommend the best policies for your needs.

First name (1)

First name (2)

Family name

Family name

Type of interest in the business eg, owner, investor etc

Type of interest in the business eg, owner, investor etc

First name (3)

First name (4)

Family name

Family name

Type of interest in the business eg, owner, investor etc

Type of interest in the business eg, owner, investor etc

Years in operation This business years

Sales turnover / fees $

Rent receivable (if applicable) $

Any similar business years

Employees: Directly employed by the business Number

Labour hire on employees Number

Wages

Wages

$

$

Work type

Work type

What percentage of GST do you claim as an Input Tax Credit?

Do you maintain complete records of sales and purchases?

Are your books of account prepared by an external accountant?

%

RESET

Yes

SAVE

PRINT

No

Yes

No


Have you or any director/partner/manager of the business ever had: Donnellys Range of Policies

(a) insurance declined or cancelled? Yes

• Fire and Extended Perils

No

(f) been declared bankrupt or put into receivership or liquidation? Yes

No

(b) an insurer refuse or not invite renewal?

• Theft

Yes

• Business Interruption • Property Owners – Rent Default

(g) been charged with or convicted of a criminal offence?

No

(c) any special conditions imposed on a policy of insurance?

• General Property/ Portable Items

Yes

Yes

No

If answered ‘Yes’ to any of the above questions provide complete details:

No

(d) a special excess imposed on a policy of insurance?

• Money • Glass

Yes

• Corporate Travel

No

(e) a claim rejected under a policy of insurance?

• Commercial Motor/Fleet • Management Liability

Yes

No

• Electronic Equipment • Employee Fraud

YOUR CLAIMS HISTORY:

• Goods in Cold Storage • Machinery Breakdown

In the last 5 years have you sustained loss or damage (insured or not) of a type against which insurance is now being sought?

• Marine Cargo

If 'Yes', please provide details:

• Personal Accident & Sickness

Date

Insurer /

• Public/Products Liability • Tax Audit Contingency

Amount of claim

/

Details

$

• Professional Indemnity Date

• Credit Insurance

Insurer /

• Staff Personal

Amount of claim

Donnellys Financial Services

Details

$ Date

• Income Protection

Insurer /

• Life Insurance • Key Man • Business Insurance

/

/

Amount of claim

Details

$

• Trauma/Critical Illness

Date

• Superannuation

Insurer /

Amount of claim

/

Details

$ Date

Insurer /

Amount of claim

/

Details

$

RESET

SAVE

PRINT

Yes

No


YOUR PREMISES: Your business location(s) Street address

Suburb/Town

State

Are you the owner of the premises? Yes No

Are the premises occupied by any other businesses? Yes

Construction of the premises Walls

If yes, what activities are conducted by the other business(es)?

No

Roof

Floors

Brick/Concrete

Steel, eg Colourbond

Timber

Wood

Timber

Concrete

Steel, eg Colourbond

Concrete

Other

Other

Other

How old is the building?

Postcode

Have the premises been renovated in the last five years?

years

Yes

No

If ‘Yes’, please provide details

Has the building been rewired? Yes

No

If ‘Yes’, what year?

Locality Main Street

Shopping Centre

Is any commercial cooking done on the premises? Yes

Suburban Street

Cooking Type Grilling

No

Oven Deep frying - Cooking Oil Thermostat Controlled Yes

No

Auto Cut Off Yes

RESET

SAVE

PRINT

No

litres

Office Block


Our aim Our goal is to recommend for your consideration the best value policy we can arrange with a secure and reliable insurer. We also aim to provide you with exceptional personal service because we treat your insurance like our own when we recommend a policy to you.

FIRE PROTECTION

Alarm

Hose Reels

Extinguishers

Fire Blanket

Is there a maintenance agreement in place? Yes

No

Sprinklers

SECURITY Do the premises have an alarm system installed? Yes

If yes, is it:

No

Local alarm only

If monitored, type of dialler

Local and monitored alarm

Landline only Landline with GSM backup

Your signature(s) Your Signature

2nd Owner’s signature

Date

/

/

3rd Owner’s signature

Please return this form to enable us to provide you with the best insurance recommendation. Mail – Free Post No postage stamp is required within Australia Use your own envelope and mark it as follows: Donnelly Insurance Brokers Pty Ltd Reply Paid 1833 ADELAIDE SA 5001

Date

/

/

Policy Number

Client Reference Code

Fax (08) 8236 7700 (be sure to include all pages) Email You can scan and email to insure@donnellys.com.au Online This form can also be completed online. Go to www.donnellys.com.au/ business_profile SAVE

/

/

/

/

4th Owner’s signature

office use

RESET

Date

PRINT

Date


Email: amcrc@amcrc.com.au Phone: 61 3 9214 4780 Website: www.amcrc.com.au

ADVANCED

MANUFACTURING

CRC

Preliminary Project Proposal

Propelling Australian innovators into global manufacturing

This form is to express interest in receiving funding under the Advanced Manufacturing CRC Co-investment program. Successful applications will be invited to engage with AMCRC to develop a more detailed proposal for possible project funding.

Project title

Name of organisation

Nature of the organisation

Research

Commercial

Address

State/Territory

Principal contact

First name

Mr

Postcode Mrs

Ms

Miss

Dr

Prof

Family name

Title

Telephone

Mobile

Email

Name of supporting organisation

Type

Primary contact person

Telephone

Email

Name of supporting organisation

Type

Primary contact person

Telephone

Research

Commercial

Research

Commercial

Research

Commercial

Email

Name of supporting organisation

Type

Primary contact person

Telephone

Email

Save

Print

Reset page

Page 1 of 4


Project Description Describe the technical problem to be solved and its significance

Describe the expected tangible outputs of the project

Describe the proposed approach and phases of the project, including key activities and milestones

Technical Risks: Please indicate the key technical risks associated with the project and how these will be addressed.

Save

Print

Reset page

Page 2 of 4


Management overview Provide an overview of the management structure and capabilities

Provide an overview of the resources required and where these will be sourced from

Intellectual Property (IP) Provide details of intellectual property including any existing IP, encumbrances on existing IP, any required third party IP and the potential for this project to generate IP.

Save

Print

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Page 3 of 4


Project Target Market Please indicate the target market for the project and the associated market size and expected market growth rate over the coming 5 yrs.

Customer Needs Addressed Please provide a description of the key customer needs addressed and the associated benefits of the project to the end customer.

Post-Project Activities and commercialisation strategy After successful completion is the research â&#x20AC;&#x153;commercial readyâ&#x20AC;?? If not, describe, what additional development is required and the commercialisation path and strategy.

Please provide the expected monetary impact from the commercialisation activities

Save & Submit

Print

Reset form

Advanced Manufacturing CRC aims to respond to applications within 10 working days.

Page 4 of 4


Total project duration and cost (from all sources over the lifetime of the project)

AMCRC Funding required Please indicate the level of funding sort and the areas of the project the funding will cover. Please provide an aggregate and yearly breakdown (financial years).

Matching Funding Sources The CRC requires 1:1 cash matching funding. Please indicate source of matching funding (and status â&#x20AC;&#x201C; e.g. procured, under discussion etc).

Associated project benefits Please provide a brief description of any associated benefits of the project to Australia including environmental, educational, economic, social etc

Save & Submit

Print

Reset form

Advanced Manufacturing CRC aims to respond to applications within 10 working days.

Page 4 of 4


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