Employee Details* Surname: Aboriginal*YesNoTorres Strait Islander*YesNo* First Name: Tenant of social housing*YesNoHave a disability*YesNoAddress:* Street Address Suburb State Postcode Contact Details: Company DetailsAddress:* Street Address Suburb State Postcode Office Contact Details: QualificationsDrivers LicenceApprox date attended Tickets attainedYesNoContractors Licence CardApprox date attended Tickets attainedYesNoWhite CardApprox date attended Tickets attainedYesNoIndustry Induction CardApprox date attended Tickets attainedYesNoTrade CertificateApprox date attended Tickets attainedYesNoFirst Aid CertificateApprox date attended Tickets attainedYesNoWorking at HeightsApprox date attended Tickets attainedYesNoManual HandlingApprox date attended Tickets attainedYesNoWH&S Supervisors ListApprox date attended Tickets attainedYesNoHSR RepApprox date attended Tickets attainedYesNoElevated work platform CardApprox date attended Tickets attainedYesNoBoom lift plus 11mApprox date attended Tickets attainedYesNoScaffold ErectionApprox date attended Tickets attainedYesNoWeldingApprox date attended Tickets attainedYesNoFire extinguisher TrainingApprox date attended Tickets attainedYesNoFork Lift LicenceApprox date attended Tickets attainedYesNoRTW TrainingApprox date attended Tickets attainedYesNoWH&S ConsultationApprox date attended Tickets attainedYesNoConfined SpacesApprox date attended Tickets attainedYesNoExplosive Power ToolsApprox date attended Tickets attainedYesNoOther, please describe:Approx date attended Tickets attainedYesNoCompleted by:NameSignatureDate MM DD YYYY review (to be completed by the procurement officer and based on above assessment outcomes)Provider approved?YesNoReviewed by:Positon:SignatureDate MM DD YYYY
