Choice Personnel & Labour Hire

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Blue Stone Medical Pty Ltd

Employment Application FormDate:......

Position Applied For: NURSING ASSISTANT / EN / RN

Level:...... Permanent Rate:......

SURNAME: ……………………………… GIVEN NAMES: ……...... …………………………

ADDRESS:……………………………………………………………………………………………..…

………………………………………………………………………………P/CODE:………………..…

HOME PHONE: ………….....……...... MOBILE: …………………......

Email: ……..……………….……......

Drivers Licence No:…………………… Expiry Date: ___ / ___ / ___ Own Transport: Yes / No

Date of Birth: ___ / ___ / ___Place of Birth…………………………………….

Sex: Male / Female Uniform Size: …………………

Can you work at short notice: Yes / No Shift Work: Yes / No

Are You a Member of a Union: Yes / No If yes which Union/s?..………………...... …...

Union Numbers: (if applicable) ………………………………………………………………………..….

Tax File Number: ______- ______- ______(Complete Tax File No. Declaration)

Work Visa: (if applicable) ………………………..Expires: ___ / ___ / ___

Super Fund: ……………………………………Fund Number: ……………………...... ……...

BANK DETAILS(Complete for EFT payment of Wages)

Account Name: ………………………………… Bank: ……………...... …

Branch No: (6 digits) ______- ______Account No:……………………………...... ….
NEXT OF KIN INFORMATION(In Case of Emergency)
Next of Kin: ………………………… Relationship:……………………….. Ph:………………...…...

Address:……………………………………………………………………P/Code:…………..……..….

In Case of Emergency are there any special Requirements we should know. …………………….

…..…………………………………………………………………………………………………………..

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Employment History(list your present or most recent employer first) 2

(1) Period Employed From ___/___/___To___/___/___
(Please tick) Full Time Part Time  Casual  Temporary Contract 

Company Name:……………………………………………………………………..…………….….……

Type of Business: ..…………………………………… Suburb:...………………………………………

Reporting To : ………………………………………. Phone:…..………………………………….….

Duties: ………………………………………………………………………………………...……………

………………………………………………………………………………………………………....……..

Reason for Leaving: ………………………………………………………………………………………

(2) Period Employed From ___/___/___To___/___/___
(Please tick) Full Time Part Time  Casual  Temporary Contract 

Company Name:……………………………………………………………………..…………….….……

Type of Business: ..…………………………………… Suburb:...………………………………………

Reporting To : ………………………………………. Phone:…..………………………………….….

Duties: ………………………………………………………………………………………...……………

………………………………………………………………………………………………………....……..

Reason for Leaving: ………………………………………………………………………………………

(3) Period Employed From ___/___/___To___/___/___
(Please tick) Full Time Part Time  Casual  Temporary Contract 

Company Name:……………………………………………………………………..…………….….……

Type of Business: ..…………………………………… Suburb:...………………………………………

Reporting To : ………………………………………. Phone:…..………………………………….….

Duties: ………………………………………………………………………………………...……………

………………………………………………………………………………………………………....……..

Reason for Leaving: ………………………………………………………………………………………

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Work Experience Details 3

Please indicate against the following skills and duties your experience and level of proficiency.

Indicate Y (yes) N (no) to indicate your experience then tick the appropriate box to indicate your proficiency

1 = Highly proficient, you have preformed this duty on a daily or weekly basis

2 = Moderately proficient, this means you have preformed this duty once or twice a month

3 = Limited Experience, this means you occasionally but not regularly preform this duty

Health& Safety Declaration 5

Is Your CurrentState of Health Good? (Yes) (No) ………………………………………………...... ……

When was your last Medical check up?………………If required will you have one? Yes  No 

Do you suffer any ailments/disorders that may make it harmful for you to work in some Environments?(e.g. dusty, strenuous, noisy, height, vapours, heat etc) ……… Yes  No 

If yes what environments need to be avoided or what precautions need to be taken

……………………………………………………………………………………………………………...... …

Do you take Drugs or Medication that may affect your ability to work within the Healthcare industry? Yes  No 

If yes what Drugs or Medication do you take and what precautions need to be taken?

…………………………………………………………………………………………………………...... ……..

Do you suffer from any ailment or disorder that may make it harmful for you to preform any particular physical task? Yes  No 

If yes what precautions need to be taken or what tasks should be avoided?………………...... ……..

……………………………………………………………………………………………………...... …………

In your last Position

(a) What duties were you performing?………………………………………………………………...... ….

…………………………………………………………………………………………………………………...... ……….

(b) What did these duties require you to physically perform?

………………………………………………………………………………………...... ………..………………

(c) In carrying out these duties did you experience any difficulties or problems? (e.g. Injury or aggravation of a previous injury) Yes  No 

If yes give details ……..……………………………………………………………...... ………………………

Have you been vaccinated against?

All Hepatitis Viruses ……………………… Yes  No  Date: ___ / ___ / ___

Tetanus…………………………………….. Yes  No  Date: ___ / ___ / ___

Chicken Pox Vaccine……………………... Yes  No  Date: ___ / ___ / ___

TB Vaccine…………………………………. Yes  No  Date: ___ / ___ / ___

Workers Compensation Past history

Nature of injury/Illness……………………………………………………………..Date: ___ / ___ / ___

Do you have any Vision, Hearing Impairments pre-existing injury or disability that may put you or others at risk or limit your ability to perform your job as intended? Yes  No 

Give Details………………………………………………………...…………………………………...... ……

Have you had any Work Cover claims with your previous employers? Yes  No 

Have you got any outstanding work cover claims ? Yes  No 

Give Details …………………………………………………………………………………...... …………….

Declaration:

I hereby declare that all the information I have provided on this application is true and correct to the best of my knowledge

Signed………………………..…...... Witnessed………………………………. Date: ___ / ___ / ___

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Blue Stone Medical Pty Ltd

OH&S Declaration

(1) I have read and understood the general induction Booklet.True / False

(2) I have received and read a copy of the OH&S Rules and Guidelines. True / False

(3) I have read and understood the OH&S Rules & Guidelines True / False

(4) If you answered False to question (1) or (3) which section did you not

Understand?………………………………………………………...... ……

…………………………………………………………………...... ………

……………………………………………………………………...... ……

(5) I agree to comply with the Safety Rules & Guidelines set out in the

OH&S Rules & Guidelines leaflet I have been provided.

True / False

(6) I understand that not complying with the Rules & Guidelines may

place others or myself in danger. True / False

(7) I understand that not complying with the Rules & Guidelines may

lead to instant dismissal from the workplace. True / False

(8) I will report any incident of a near miss or a safety incident to my

immediate supervisor, OH&S Representative and my Blue Stone

Representative or consultant True / False

Client Confidentiality

(9) I understand that part of my terms of employment I will not approach

Blue Stone clients directly for employment during my employment

with Blue Stone or for a period of 3 months after completion of my

assignments with Blue Stone. (Placement Fees may apply)

(Direct placements at Blue Stone Clients can be arranged through Blue Stone) True / False

My signature below verifies that I agree to comply with the Rules & Guidelines set out

in this induction whilst in the employ of Blue StoneMedical Pty Ltd.

Signature: ……………………………………………. Date: ___ / ___ / ___

Name (Please Print): ………………………………………………………….

Blue Stone Representative: ………………………………………….…….…

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Private Employment Agents Act 2005

Private Employment Agents (Code of Conduct) Regulation 2005

Information Statement for Work Seekers

Your relationship with Blue Stone Medical & Professional is regulated by a number of Commonwealth and State laws, in particular the Private Employment Agents

Act 2005 and the Private Employment Agents (Code of Conduct) Regulation

2005 (the Code).

Prior to providing you with placement and employment services, we are obliged

as a private employment agent, to provide you, as a work seeker, with the

following information:

We must not charge you a fee for finding, or attempting to find work for you in contravention of section 408D of the Industrial Relations Act 1999.

We and our employees have a working knowledge of State and Commonwealth legislation affecting the placement and employment of work seekers.

We will ensure that all placements are made in accordance with any relevant legislative requirements.

If you believe that your agent has acted illegally, inappropriately or in a false or misleading way, you may obtain information about action that may be taken from the Department of Industrial Relations.

I, ______

(Name)

of ______

(Address)

acknowledge receiving and reading a copy of this “Information Statement for

Work Seekers”.

Signed: ______Date: _____/_____/_____

The above Information that has been provided to Blue Stone Medical Pty Ltd will be kept along with the rest of my information in accordance with the privacy act.

(A copy of our privacy policy is available on request or can be viewed on line at )

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Blue Stone Medical Pty Ltd

OH&S Rules & Guidelines

Your Responsibilities:

(1)Know and understand the safe work practices pertaining to your job requirements, co-workers and the workplace. Don’t work outside your scope of practice.

(2)Comply with all requirements regarding safe work practices, personal protective clothing and other equipment as required.

(3)Report all incidents or accidents to your workplace supervisor and to a Blue Stone Representative immediately. In the instance of risk to health or safety the work may need to be suspended until the problem is resolved.

(4)For your safety and the safety of others please make sure you are fully aware of all of the correct work procedures before commencing work. This may involve work site orientations, on the job training etc. If you are unsure ask your workplace supervisor or a Blue Stone Representative.

(5)Notify Blue Stone immediately of any change in your job description.

Note: Using a Walkman or mobile phone whilst working may result in immediate dismissal from the site you are on, during your working hours. Please keep your phone on vibrate or silent and if you miss a call from the office, please call back on your break.

As your employer we care about your safety and will take all necessary steps to ensure that you are provided with all the necessary personal protective equipment, any training or alterations to your workplace etc to minimise the risk of injury. Safety also depends on you to report any injuries or hazards immediately so that the appropriate action can be taken.

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Blue Stone Medical Pty Ltd

General Safety Rules

(1)No employee will perform a job until he/she has been fully trained on how to do the job properly/safely and has been authorised to perform that job.

(2)Do not perform any work that you or others may consider potentially dangerous to yourself or other people/equipment. Don’t transfer any residents on your own. All transfers must be a “two person transfer”.

(3)No employee is to use or handle any chemicals without the knowledge of their potential dangers (if any) or without the correct personal protective equipment.

(4)Any work related injuries, accidents, potential hazards or near misses are to be reported immediately to your workplace supervisor and to Blue Stone to ensure the correct forms are completed and action taken.

(5)Obey all workplace rules, signs, government regulations and instructions.

(6)Always use the right equipment for the job to be performed, (if you are not sure ask your supervisor) eg Slide sheets, walking belts, pixel hoists, hoists etc

(7)Never operate a hoist or any electronic equipment on your own. Always adhere to safe work practices.

(8)Always stand clear of operating equipment.

(9)Do not use any defective equipment, worn electrical wiring, overloaded power outlets or any machinery with danger/warning isolation tags attached.

(Report all worn or defective equipment to your workplace supervisor).

(10)Long hair must be tied back or keep neat and tidy whilst on shift. Minimum jewellery must be worn to protect you from having it pulled by residents

(11)When ascending or descending stairs always use the hand rail, do not run in any workplace, always open and close doors carefully and slowly.

(12)Do not stand on chairs; tables etc., to obtain articles out of reach always use the correct access equipment.

(13)Keep all draws cabinet doors closed when not in use. Store all tools, equipment boxes and rubbish etc in the correct places to avoid tripping or striking hazards.

(14)When lifting heavy objects always utilise recommended lifting techniques.

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Blue Stone Medical Pty Ltd

Important Information

Fire Emergency

It is important for you to know the following:

(1)Workplace evacuation procedure and assembly area.

(2)The location and correct use of fire extinguishers.

(3)Location of breathing apparatus (if required)

Should this information not be supplied at the host employer’s workplace through the induction/orientation process then ask your immediate supervisor or the OH&S representative.

Housekeeping

An untidy workplace is inefficient and can cause hazards and accidents.

Store all tools, equipment boxes and rubbish etc in the correct places to avoid tripping or striking hazards.

Keep all walkways and exit doors clear of obstacles.

Good housekeeping is important in all workplaces for your safety and for the safety of others.

A tidy workplace allows you to be more productive.

Smoking

Blue Stone promotes a smoke free work environment.

Smoking in the workplace is generally prohibited. Should you be caught smoking in a non-smoking area you may be dismissed from your host employer’s workplace.

Smoking is bad for your health. However, if the need arises use only the designated times and areas to do so.

Drugs & alcohol

Bringing drugs or alcohol into a workplace or reporting for work under the influence of drugs or alcohol is strictly forbidden and will lead to instant dismissal.

Prescribed drugs need to be reported to your supervisor and to Blue StoneMedical & Professional before you commence work, as they may impede your work performance and the use of machinery, which may place you and others in danger.

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Important Guidelines and Information

Please ensure you are on time for the start of your shift. It is important for you,
Blue Stone Medical and the company you are on assignment with, that you are a good timekeeper!

On the first day of any new assignment, please ensure you are 10-15 minutes early. This is in case you should you run into any difficulties on your journey, you are not too late. It also creates a good impression on you first day if you arrive with enough time for the Blue Stone Medical representative to show you the site and help prepare you for your shift.

Make sure you are wearing your uniform and appropriate footwear when you are working or on site.

If at any time you must leave a company for whatever reason, you must inform the supervisor of the site, and most importantly, you must telephone a Blue Stone Medical consultant. Remember! Do not just walk off a site without telling a representative of Blue Stone Medical.

Pay Rates and allowances will be explained to you when the Blue Stone Medical consultant is booking you into your job. If they don’t tell you, it is your responsibility to ask.

If you are going to be late for the start of your shift, please call the Blue Stone office and let them know. They will then tell the company you are working for. This stops people trying to find out where you are and stops people worrying unnecessarily.

Private Employment Agents Act 2005

Private Employment Agents (Code of Conduct) Regulation 2005

Prior to providing you with placement and employment services,

Blue Stone Medical & Professional are obliged as a private employment agent,
to provide you, as a work seeker, with the following information:

We must not charge you a fee for finding, or attempting to find work for you in Contravention of section 408D of the Industrial Relations Act 1999.