DEPARTMENT DATA COLLECTION FORM
Title / Question / Value As At 1 Nov 20** (overtype with year-ending)SECTION 1 / GENERAL INFORMATION
1.1 University’s Description of Business Activities / Educational and Research institution and all affiliated activities whether for research or commercial purposes, Researchers, Testers, Developers, Consultants, Facilitators, Product and Process Testers, Technology Commercialisers, Manufacturers, Distributors, Publishers, Promoters, Property Owners, Lessees, Lessors, Occupiers and Developers, Producers, Trustees, Venue Hirers, Restaurateurs, Conference Organisers and Managers, Farmers, Graziers, Generators and Resellers of Electricity, Internet Service Providers, Peak Bodies, Joint Venture Participants and any other occupations incidental to Universities or similar Educational and/or Research Institutions or their Affiliated Bodies. Providers of: Student services and all recognised Student activities; Admissions Services; Postal Services; staff and student amenities and social clubs; Religious and Residential Services. Owners and Operators of: Museums, Galleries, Theatres, Feedlots, Cinemas, Catering Facilities, Child Minding Facilities, Child Care Facilities, Bars, Hotels, Radio Stations, Newsagencies, Hairdressing Salons and other retail outlets.
1.1 (a) Business Activities / Is the Department involved in any activities that are not included in the above business activity description? / YES / NO
1.1 (b) Additional Business Activities / If you have answered YES to the above question 1.1 (a), please provide details of the additional business activities.
Faculty/School / Department / Additional Business Activities
SECTION 2 / PROPERTY
2.1 Property on Loan / Property owned by a third party and in the care custody or control of UWA including leased equipment.
2.1 (a) / Provide the total replacement value for all property on loan. / $
2.1(b) / Provide details of property on loan
2.2 Fine Arts
2.2 (a) / Provide the total replacement value for works of art / $
2.2 (b) / Provide details of the Works of Art
2.3 Library Collections / EG Department Reference Books, Magazines, Journals etc
2.3 (a) / Provide replacement value of the Library Collections / $
2.3 (b) / Provide details of the Library Collections
2.4 Rare Books
2.4 (a) / Provide replacement value of the Rare Books / $
2.4 (b) / Provide details of the Rare Books
2.5 Valuable Paper and Records / Includes items of historical, heritage or special value
2.5 (a) / Provide replacement value of the Valuable Papers and Records / $
2.5 (b) / Provide details of the Valuable Papers and Records
2.6 Animals (Research and Development) / Cost to reinstate animals to pre-loss state
2.6 (a) / Provide replacement value of the Animals (Research and Development) / $
2.6 (b) / Provide details of the Animals (Research and Development)
2.7 Animals (Commerical & Farm Purposes)
2.7 (a) / Provide replacement value of the Animals (Commerical & Farm Purposes) / $
2.7 (b) / Provide details of the Animals (Commerical & Farm Purposes)
2.8 Research Specimens (Research & Development) / Not included in above categories
2.8 (a) / Provide replacement value of the Research Specimens (Research & Development) / $
2.8 (b) / Provide details of the Research Specimens (Research & Development)
2.9 Research Projects
2.9 (a) / Provide replacement value of the Research Projects / $
2.9 (b) / Provide details of the Research Projects
2.10 Temperature Controlled Environments / Includes Freezers, Fridges, Cold Rooms, Growth Rooms, Incubators, Dewars etc
Complete the table for all TCEs within your Department / Type of Appliance / Number of Appliances / Area/Section
/Unit / Location including Postcode / Staff Member Responsible for Appliance / -80c Freezer Y/N / Back-to-base Alarm Y/N / Audible Alarm Y/N / Maintenance Agreement Y/N / Automatic Power Backup Y/N / Value of Contents / Comments
2.11 Crops & Pastures (Commerical & Farm Purposes)
2.11 (a) / Provide replacement value of the Crops & Pastures (Commerical & Farm Purposes) / $
2.11 (b) / Provide details of the Crops & Pastures (Commerical & Farm Purposes)
2.12 Crops & Pastures (Research and Development)
2.12 (a) / Provide replacement value of the Crops & Pastures (Research and Development) / $
2.12 (b) / Provide details of the Crops & Pastures (Research and Development)
2.13 Farm Fencing & Gates
2.13 (a) / Provide replacement value of the Farm Fencing & Gates / $
2.13 (b) / Provide details of the Farm Fencing & Gates
2.14 Other Miscellaneous / Other (please specify if there is another category not listed above that needs to be declared
2.14 (a) / Provide replacement value of the Other Miscellaneous / $
2.14 (b) / Provide details of the Other Miscellaneous
2.15 Overseas Assets / Assets located overseas are required to be declared
2.15 (a) / Provide replacement value of the Overseas Assets / $
2.15 (b) / Provide details of the Overseas Assets
2.16 Food and Beverage Manufacture
2.16 (a) Food and Beverage Manufacture / Does the Department undertake the manufacture of any type of bulk food or beverage eg wine, cheese etc? / YES / NO
2.16 (b) Details of Bulk Food or Beverage / If YES to above question 1.2, please provide details including product and annual revenue.
Faculty/School / Department / Description / Revenue per annum
SECTION 3 / GENERAL AND PRODUCTS LIABILITY
3.1 Goods or Products Sold or Supplied / Does the Department manufacture, sell or supply goods or products for/to any external entities? / YES / NO
3.1 (a) Details of Goods or Products / If YES to the above question 1.3, please provide details of the goods or products including description of products.
Faculty/School / Department / Details of Goods or Products / Annual Revenue
3.2 Service of Alcohol / Does the Department operate a tavern or other facilities where alcohol is sold? / YES / NO
3.2 (a) Responsible Service of Alcohol / If YES to the above question 1.4, does the Department follow the Responsible Service of Alcohol Rules? / YES / NO
3.3 Child Care Facility / Does the Department own and/or operate a child care facility? / YES / NO
3.3 (a) Child Care Facility Listing / If YES to the above question 1.5, please provide details in the table below.
Name of Facility / Number of Carers / Number of Licensed Places / Age Range of Children / Operating Hours / Annual Turnover/Revenue / Notes
3.4 Overseas Entities / Does the Department own any entities incorporated or domiciled overseas or have any operations domiciled overseas? / YES / NO
3.4 (a)Overseas Entity Listing / Faculty/School / Department / Entity / Country of Domicile/Incorporation / Description of Activity / Annual Revenue
FACTS &/OR CIRCUMSTANCES WHICH MAY LEAD TO CLAIMS
1.8 Possible Claim / After making specific enquiries to staff, does anyone have any knowledge of any facts or circumstances which have occurred which could give rise to a liability claim against the University, staff or student? / YES / NO
1.8 (a) Possible Claim Details / If YES to the above question 1.8, please complete the table below.
Faculty/School / Department / Date / Details of Facts or Circumstances
SECTION 4 / PROFESSIONAL LIABILITY
4.1 Consultancies and/or Professional Services / List consultancies or professional services where the fee exceeds $50,000
Department / Client (the party requesting the consultancy or service / Description of Consultancy / Fee/Income
4.2 Professional Indemnity Possible Claim / Please advise details of any Facts or Circumstances which may lead to a Claim and include the date it occurred and the date the persons fist become aware. (A "Claim" means any demand made by a third party upon the University for compensation, however conveyed, including a letter of complaint, a legal writ, statement of claim etc
Date of Loss / Claimant Details / Who was the claim made against / Brief Description of the Incident or Claim
SECTION 5 / DIRECTORS AND OFFICERS LIABILITY
5.1 Directors and Officers Liability Possible Claim / After making specific enquiry to faculties, departments, staff and each nominated affiliate, does anyone have any knowledge of any facts or circumstances which have occurred which could give rise to a claim against any Director or Officer of the Member or nominated affiliate, in their capacity as Directors or Officers of the Member or nominated affiliate or in their capacity as a Director? / YES / NO
5.1 (a) D&O Possible Claim / If you have answered YES to the above question
please provide details.
SECTION 6 / MARINE CARGO (Property in Transit)
6.1 Property in Transit Declaration / Please complete table below if applicable
Type of Goods / Nature of Packing / Method of Transport / Value of Goods – Year to Date / Value of Goods – Next 12 months
SECTION 7 / MARINE HULL
7.1 Details of Marine Hull / Provide details in the table below of any Marine Craft that is Owned, Required to be Insured by your Department
Serial/Boat No / Replacement Value / Make/Model/Full Description of Marine Craft
SECTION 8 / PERSONAL ACCIDENT (VOLUNTEERS)
8.1 Estimated Volunteers / Please provide the following (estimated) details, where applicable, to identify the Volunteers likely to be engaged by your Department.
Type of Volunteer Work / No of Volunteers / Location of Work / Likely Period of Engagement
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