Aged Care Worker Screening Form

Comments

This field is for validation purposes and should be left unchanged.

Date

Role of aged care worker

Department

Name(Required)

First Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

National Police Check less than 3 years old:

Document has been checked, copy taken and certified

Are there any precluding offences listed on the police check?

No

Yes (unable to work in aged care. For all other offences a risk assessment must be cmpleted. Please contact the EMQOD or Workforce Coordinator for guidance)

Has the aged care worker been a resident or citizen of any other country since the age of 16?

No

Yes (ask them to complete a statutory declaration which must be certified)

Banning Order Check

Has the aged care worker been a resident or citizen of any other country since the age of 16?

They are not listed on the banning orderes

They are listed on the banning orders (unable to work in aged care)

Code of Conduct/Statement of Rights Training Package Complete

Has the aged care worker been a resident or citizen of any other country since the age of 16?

Yes

CARE STAFF (Care Partners, Care and Support Workers – PVL Employees and agency staff)

I have cited their Certificate III in Individual Support (or equivalent)

Yes

No

REGISTERED NURSES and ALLIED HEALTH STAFF (PVL Emloyees and agency/contractor staff)

Their registration is current with norestrictions on AHPRA

Yes

No

Registration Number

MAINTENACE CONTRACTORS – Induction Checks

I have cited their tradesperson licence?

Copy taken and attached

N/A

Public Liability Insurance

Copy taken and attached

Workers Compensation Insurance

Copy taken and attached

White Card

Copy taken and attached

Has been provided ith and read and understood the Safe Work Method/WHS Policy

Yes

Contractor Induction Provided and declaration signed?

Yes

AGENCY CARE STAFF (Care Partners, Registered Nurses) – please ensure the agency staff member s recorded in the Agency Staff Database. If not, please eneter their details)

Agency handbook provided and read and understood

Yes

No

Agency orientation provided (checklist completed and included with this form)

Yes

No

Qualification Check

Screening completed as per Trello Checklist

Yes

No

ALL WORKERS

Aged Care Worker – All information contained on this form is correct and I agree to the details and documents provided being retained

Yes

Aged Care Worker Signature

Date

Peninsula Villages Supervisor – I have checked all areas of the form as per the requirements

Yes

Supervisor Signature

Date

Discover the Peninsula Villages
difference

One

Continuity of care

Two

Residents become family

Three

Live life your way

Four

Community-owned