Employee Details* Surname: Aboriginal* Yes No Torres Strait Islander* Yes No * First Name: Tenant of social housing* Yes No Have a disability* Yes No Address:* Street Address Suburb State Postcode Contact Details:PhoneEmail Company DetailsCompany Name:Address:* Street Address Suburb State Postcode Office Contact Details:PhoneEmail QualificationsDrivers LicenceApprox date attended MM slash DD slash YYYY Tickets attained Yes No Contractors Licence CardApprox date attended MM slash DD slash YYYY Tickets attained Yes No White CardApprox date attended MM slash DD slash YYYY Tickets attained Yes No Industry Induction CardApprox date attended MM slash DD slash YYYY Tickets attained Yes No Trade CertificateApprox date attended MM slash DD slash YYYY Tickets attained Yes No First Aid CertificateApprox date attended MM slash DD slash YYYY Tickets attained Yes No Working at HeightsApprox date attended MM slash DD slash YYYY Tickets attained Yes No Manual HandlingApprox date attended MM slash DD slash YYYY Tickets attained Yes No WH&S Supervisors ListApprox date attended MM slash DD slash YYYY Tickets attained Yes No HSR RepApprox date attended MM slash DD slash YYYY Tickets attained Yes No Elevated work platform CardApprox date attended MM slash DD slash YYYY Tickets attained Yes No Boom lift plus 11mApprox date attended MM slash DD slash YYYY Tickets attained Yes No Scaffold ErectionApprox date attended MM slash DD slash YYYY Tickets attained Yes No WeldingApprox date attended MM slash DD slash YYYY Tickets attained Yes No Fire extinguisher TrainingApprox date attended MM slash DD slash YYYY Tickets attained Yes No Fork Lift LicenceApprox date attended MM slash DD slash YYYY Tickets attained Yes No RTW TrainingApprox date attended MM slash DD slash YYYY Tickets attained Yes No WH&S ConsultationApprox date attended MM slash DD slash YYYY Tickets attained Yes No Confined SpacesApprox date attended MM slash DD slash YYYY Tickets attained Yes No Explosive Power ToolsApprox date attended MM slash DD slash YYYY Tickets attained Yes No Other, please describe:Approx date attended MM slash DD slash YYYY Tickets attained Yes No Completed by:NameSignatureDate Month Day Year review (to be completed by the procurement officer and based on above assessment outcomes)Provider approved? Yes No Reviewed by:Positon:SignatureDate Month Day Year
