Introduction

In order to be considered for employment in any capacity at ac.care, you must complete all components of this declaration, including additional, supporting information and documentation where a ‘yes’ response has been recorded. You may also be required to agree to other pre-employment processes.

Information in this declaration is necessary to assess your suitability to be offered employment within ac.care, having regard to your ability to perform the technical aspects of a role and your character, prior conduct, and ethical obligations.

Some information is necessary to ensure ac.care and responsible officers comply with their obligations under the Work Health and Safety Act 2012 and to meet workplace diversity and inclusion targets.

Please be aware that the definition of misconduct in the ac.care Discipline Policy includes concealment of information during the selection and interview process and providing a false statement in connection with an application for engagement as an ac.care employee.

If you have any questions about the declaration and/or as to supporting information, please contact HR@accare.org.au

The information provided will be treated as confidential and dealt with in accordance with the State Records Act 1997, the destruction schedules issued under that Act

SECTION 1: EMPLOYEE DETAILS

Title: (Mr, Mrs Etc.)	Click or tap here to enter text.	Date of Birth:	Click or tap to enter a date.
First Name:	Click or tap here to enter text.	Surname:	Click or tap here to enter text.

SECTION 2: LICENCES, CERTIFICATES AND TRAINING (ALL EMPLOYEES)

ac.care is a child-safe organisation, requiring all employees to be screened for suitability to work with children and vulnerable people. In the table below, please identify the screening, licenses or training you have.

Description	Have	ID/Number	Expiry Date
Department of Human Services (DHS) – Working with Children Check (WWCC)	Choose an item.	Click or tap here to enter text.	Click or tap to enter a date.
National Police Clearance (conducted within last 12 months)	Choose an item.	Click or tap here to enter text.	Click or tap to enter a date.
Provisional or C Class driver’s licence	Choose an item.	Click or tap here to enter text.	Click or tap to enter a date.
Psychological Suitability Assessment [if working in a residential care house];	Choose an item.	Click or tap here to enter text.	Click or tap to enter a date.
Safe Environments - Through their Eyes	Choose an item.	Click or tap here to enter text.	Click or tap to enter a date.
COVID Vaccination*	Choose an item.	Click or tap here to enter text.	Click or tap to enter a date.

* ac.care requires all staff, including volunteers and students undertaking Vocational Placement, to hold a valid COVID-19 Digital Vaccination Certificate (PDF) accessed through MyGov/Medicare. If you do not have evidence of a valid COVID-19 vaccination you may not be able to undertake employment with ac.care.

SECTION 3: EMPLOYMENT DECLARATION

Employee demographics

Are you authorised to work in Australia?	Choose an item.
Do you identify as Aboriginal and/or Torres Strait Islander origin?	Choose an item.
Do you need any assistance because of a disability?	Choose an item. If yes, please give details: Click or tap here to enter text.
Are you currently a registered foster carer, or do you have an application in progress or intend to apply to become a registered foster carer, with ac.care or any other agency?	Choose an item.

Medical and/or Disability

Do you currently have any medical condition or disability (including learning disability) which might prevent or impede you from being able to satisfactorily perform any duties or functions that might be reasonably required of you in the role for which you have applied?	Choose an item.
Please give further information if ‘yes’ or ‘unsure’ has been ticked (include details of any medications/ assistance/adjustments that may reasonably be required so that you can perform the inherent requirements of the role): Click or tap here to enter text.

Criminal History

Have you ever been investigated or found guilty of any criminal offence excluding spent convictions in accordance with the Spent Convictions Act 2009, including any traffic offences not resolved by expiation?	Choose an item.
Have you ever been the subject of allegations of conduct by you towards a child (Person under 18 years of age) that if proven would have amounted to criminal conduct or would have constituted misconduct in an employment setting?	Choose an item.
Are you currently facing criminal charges yet to be finalised?	Choose an item.
Have you ever been convicted for driving under the influence of alcohol, drugs or had a licence cancelled or suspended in the last 5 years?	Choose an item.
Please give further information if ‘yes’ has been ticked: Click or tap here to enter text.

Employment History

Has your employment been terminated by any organisation, for any reason?	Choose an item.
Have you been the subject of allegations or an investigation or any other process relating to alleged unsatisfactory performance or misconduct by you as an employee?	Choose an item.
Are you currently, the subject of an investigation or any other process relating to suspected or alleged misconduct or other unsatisfactory performance by you?	Choose an item.
Please give further information if ‘yes’ has been ticked: Click or tap here to enter text.

Insurance

Have you ever had motor vehicle insurance declined/cancelled/conditions imposed in the last 5 years?	Choose an item.
Please give further information if ‘yes’ has been ticked: Click or tap here to enter text.

I declare that the information in this declaration completed by me and/or any other statement made by me in support of my application for employment with ac.care, is true and correct in every detail.

I understand that if I provide any false or misleading information my application for employment may be declined, or, in the event I am employed or continue employment with ac.care, will render me liable to disciplinary action, including termination of employment.

Click or tap here to enter text.	Click or tap to enter a date.
Signature	Date