HEALTH CARE REGISTRATION FORM

Step 1 of 7

Personal Details

Given Name *

Family Name *

Sex (PLEASE CIRCLE) *

Male
Female

Date Of Birth//

Are you an Australian Citizen? (PLEASE CIRCLE): *

(If NO, please provide passport)

(CONTACT DETAILS) CURRENT residential address:

(Contact phone number/s) MOBILE:

LANDLINE:

EMAIL ADDRESS (only if you check it): *

QUALIFICATIONS Please mark / list all education and qualifications (Documents will need to be provided before commencing work)

Registered Nurse (RN)

Length of experience: In Years

Selected Value: 0

Enrolled Nurse (EN) In Years

Selected Value: 0

(RN & EN Must have valid Nursing Registration)

Personal Care Attendant (PCA) Do you have a Certificate III or above: YES / NO

Length of experience: In Years

Selected Value: 0

Community Assistance / Carer Length of experience:

Selected Value: 0

First Aid Certificate:

Last completed://

NDIS Clearance: Expiry date://

Working with Children Card (Ochre Card)

Expiry date://

Driver Licence

EXPERIENCE

What areas are you experienced in: (Please tick all appropriate areas)

Other: (Please list specific area/s below)

AVAILABILITY

Are you currently working:

Can you provide your current roster:

Are you looking for:

Are you available:

CONTRACTOR ACKNOWLEDGEMENT

Contractor name: *

First

Last

Address:

Address Line 1

Address Line 2

City

State

Zip Code

I acknowledge that I have attended:

1. The Odco Contracting® system interview and explanation session: I understand my status as an independent contractor and have had the taxation, superannuation and insurance obligations explained to me.

2. The Occupational Health & Safety briefing: I understand my responsibilities as an independent contractor to always conduct myself in a safe manner and not do anything that may cause injury to others or myself. If I am requested to work in an unsafe manner, or to perform work that I am not properly trained or qualified for, I understand the need to communicate my concerns to management and Territory Disability Services.

3. The Equal Opportunity and Anti-discrimination briefing: I understand my responsibilities as an independent contractor to always conduct myself in a manner that will not discriminate against others. If I believe that I am discriminated by others when working through Territory Disability Services. I understand the need to report my concerns to Territory Disability Services.

Signature

Date / Time//

INDUCTION PRESENTER

I confirm that I have delivered Territory Disability Services Induction Program with above named contractor.

Employee Name: *

First

Last

Signature

Position:

Date / Time//

Contractors Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

AGREEMENT TO CONTRACT

CONDITIONS OF CONTRACT

1. I acknowledge and agree that there is no relationship of employer / employee with TERRITORY DISABILITY SERVICES and that TERRITORY DISABILITY SERVICES does not guarantee me any work. I am self-employed and, as such, I am not bound to accept any work through TERRITORY DISABILITY SERVICES.

2. I hereby agree to work for an agreed amount per hour for actual on-site hours, or job price to be agreed.

3. I instruct TERRITORY DISABILITY SERVICES to make deductions under the PAYG system of taxation.

4. I hereby agree that I have no claims on TERRITORY DISABILITY SERVICES in respect of Holiday Pay, Long Service Leave, Sick Pay, or any similar payment.

5. I hereby agree that TERRITORY DISABILITY SERVICES has no responsibility or liability to me, except that I am guaranteed to be paid for actual on-site hours worked or agreed job price for work done.

6. It is agreed that I must carry out all work that I agree to do through the agency of TERRITORY DISABILITY SERVICES in a proper manner and TERRITORY DISABILITY SERVICES is hereby guaranteed against faulty work. All work must be made good. Further, I agree to cover the work (where necessary) for Public Liability, Accident Insurance, Long Service, and Holiday Pay, and have no claims on TERRITORY DISABILITY SERVICES in respect of the above

7. I hereby agree to supply my own equipment, including safety equipment, where necessary to perform the work, and that I have no claim on TERRITORY DISABILITY SERVICES in respect of the above. Territory Disability Services may provide you with company property during the course of your ODCO contract such as computers and clothing. The provision of any such company property is contingent on your role and will be provided at the absolute discretion of Territory Disability Services. You will not have a contractual entitlement to such company property, and it may be withdrawn by Territory Disability Services at any time. You must ensure that all company property in your possession or control is properly cared for and maintained. Any company property must be used in accordance with any applicable workplace policy. Personal use is not permitted other than as provided for by any workplace policy (or as otherwise expressly allowed for by Territory Disability Services).

8. Workplace Policies Territory Disability Services may from time to time have written workplace policies in place which deal with a variety of matters concerning how the workplace operates, procedures to be followed and expectations in relation to particular aspects of the business. The purpose of these policies is to make clear what Territory Disability Services expects from you in relation to the aspect of the business dealt with by the policy.

You are required to be familiar with the content of all such policies, and to comply with their terms at all times. Any failure to do so may result in disciplinary action up to and including termination of employment. If you are uncertain of where these polices are located or what obligations they impose, you have an express obligation to raise this with your manager. Your manager will then provide you with, or direct you to, the required information. To the extent that the policies describe benefits and entitlements for the Employee or impose any obligations on Territory Disability Services, these are discretionary in nature and are not intended to be contractual. The terms and conditions of your employment that are intended to be contractual are set out in this contract. Territory Disability Services may unilaterally introduce, vary, remove or replace policies at any time during the course of your employment.

9. Intellectual Property You acknowledge and agree that it is a condition of ODCO Contract that Territory Disability Services shall be the owner of all Intellectual Property Rights in everything created, generated or contributed to by you in the course of your employment:

• whether alone or in conjunction with others;

• whether during office hours or otherwise;

• irrespective of where the creation, generation or contribution took place;

• which:

o relates to the business or prospective business of Territory Disability Services; or

o was created, generated or contributed to using any equipment or facilities of Territory Disability Services

You must do all things necessary to enable Territory Disability Services to confirm or perfect the Intellectual Property Rights assigned under this clause. You consent to any act or omission by or on behalf of or authorised by Territory Disability Services, or Territory Disability Services’s assignees, licensees or successors in title and any person authorised by Territory Disability Services, or its assignees, licensees or successors in title which would otherwise infringe any part of your moral rights that subsist in any copyright works created by you. “Intellectual Property Rights” means all intellectual property rights as defined by law including without limitation:

• know how, trademarks, business names, the right to have confidential information kept confidential, copyright, inventions, improvements, designs, patents, discoveries, concept, circuits or other eligible layouts, numeric data, data or formulae, software, coding, models, drawings, plans, trade secrets, secret processes, reports, proposals, concepts or ideas;

• any rights in respect of (a); and

• any application or right to apply for registration of any of (a).

This clause will survive the termination of your ODCO Contract, irrespective of the basis of the termination, and shall remain in full force and effect indefinitely

10. Conflicts of interest You are required to immediately disclose any potential, perceived or actual conflict of interest (whether direct or indirect) that may give rise to a conflict with the performance of your ODCO Contract obligations to Territory Disability Services, or Territory Disability Services’s business or reputational interests. Territory Disability Services may require you to take action to eliminate or reduce any such conflict. In the event that in the opinion of Territory Disability Services you fail or refuse to declare any such conflict, or to resolve it in a manner satisfactory to Territory Disability Services in accordance with its directions, then notwithstanding any other provision of this contract, Territory Disability Services may terminate your employment on an immediate basis.

11. Privacy You consent to Territory Disability Services collecting and using personal information and sensitive personal information as defined in the Privacy Act 1988 (Cth) for any purpose relating to your ODCO Contract with Territory Disability Services. The personal information will be held in a secure location. You also consent to Territory Disability Services disclosing personal information and sensitive personal information about you to other persons for reasons relating to your ODCO Contract or for Territory Disability Services ’s business requirements. These persons include the Australian Tax Office, superannuation fund trustees and administrators, insurers, medical or occupational practitioners, financial and legal advisers, potential purchasers on sale of business and law enforcement bodies. You also consent to Territory Disability Services disclosing your personal information and image or likeness for marketing purposes including on Territory Disability Services’s website. This clause will survive the termination of your employment, irrespective of the basis of the termination, and shall remain in full force and effect indefinitely.

12. Restraint of Trade As consideration for your remuneration and you acquiring knowledge of the confidential information and intellectual property of Territory Disability Services and its affiliated entities in Australia, you agree that, whilst ODCO Contract by us and for the applicable Restraint Period, you must not directly or indirectly undertake any of the following activities without obtaining our prior written consent or approval: • canvass or solicit, or attempt to canvass or solicit, the business of any client (in relation to the provision of the type of services you provided at Territory Disability Services) with whom you have had direct dealings in the 12 month period prior to your ODCO Contract ending; and • induce or attempt to induce or solicit professional staff, including but not limited to directors, employees and ODCO Contractors of Territory Disability Services with whom you otherwise have had direct dealings in the 12-month period prior to your ODCO Contract ending to leave their employment with Territory Disability Services.

For the purpose of this clause:

(a) “Restraint Period” means the following periods after your employment ends (for any reason):

(b) 12 months, or if that is unenforceable;

(c) 6 months, or if that is unenforceable

(d) 3 months.

Restraint Area" means:

(a) Australia, or if that is unenforceable; (b) The State, Territory or jurisdiction in which you predominantly worked during the 12- month period prior to your employment ending.

You acknowledge and agree that:

• the restraints set out in this clause are reasonable and necessary in the circumstances to protect our legitimate business interests, including our confidential information and goodwill. • the restraints set out in this clause do not unreasonably restrict your right to practice in your profession. • the restraints set out in this clause are intended to operate to the maximum extent. • damages may be inadequate to protect the Territory Disability Services Group's interests and we are entitled to seek and obtain injunctive relief, or any other remedy, in any court. • each restraint contained in this clause (resulting from any combination of the wording in clause 1 and the definitions of Restraint Period and Restraint Area) constitutes a separate and independent provision, severable from the other restraints. If any such restraints are determined to be unenforceable in whole or in part, the enforceability of the remainder of that restraint and any other restraint will not be affected. • your obligations under this clause survive the termination/ending of your ODCO Contract. • if there is any inconsistency or contradiction between the restrains which are not invalid or unenforceable, the restraint with the longest Restraint Period and the widest Restraint Area, to the exclusion of any other prohibition or restraint, constitutes the agreed restraint

13. Workplace Policies Territory Disability Services may from time to time have written workplace policies in place which deal with a variety of matters concerning how the workplace operates, procedures to be followed and expectations in relation to particular aspects of the business. The purpose of these policies is to make clear what Territory Disability Services expects from you in relation to the aspect of the business dealt with by the policy.

You are required to be familiar with the content of all such policies, and to comply with their terms at all times. Any failure to do so may result in disciplinary action up to and including termination of employment. If you are uncertain of where these polices are located or what obligations they impose, you have an express obligation to raise this with your manager. Your manager will then provide you with, or direct you to, the required information.

To the extent that the policies describe benefits and entitlements for the ODCO Contract or impose any obligations on Territory Disability Services, these are discretionary in nature and are not intended to be contractual. The terms and conditions of your ODCO Contract that are intended to be contractual are set out in this contract. Territory Disability Services may unilaterally introduce, vary, remove or replace policies at any time during the course of your ODCO Contract.

SIGNED: (CONTRACTOR)

Date //

SIGNED: (ON BEHALF OF: TERRITORY DISABILITY SERVICES)

Date//

GENERAL DEDUCTION & PAYMENT AUTHORITY

Please make the following deductions and contributions associated with my remuneration. I have had the options explained and understand that the amounts so authorised will be forwarded to the appropriate institutions on my behalf. I also understand that the insurance deductions are after-tax deductions, and may be available to me as a tax deductible business expense.

PUBLIC LIABILITY INSURANCE & WORKERS COMPENSATION: (compulsory – refer to Contractor Guide): I wish to participate in the group fund. □ Company rate will be deducted from Gross payments and administered for Public Liability and Workers compensation.

TAXATION: TERRITORY DISABILITY SERVICES can offer the option of your remuneration being taxed at a flat rate (minimum 20%) or as per the PAYG tax tables. You may instruct us to deduct a flat rate higher than 20%, whereby an Upwards Variation declaration is required.

Deduct PAYG tax as per the Tax Tables
Deduct PAYG tax at the flat rate of 20% (If annual earnings are under $100,000)
Deduct PAYG tax at the flat rate of 25% (If annual earnings are over $100,000)
Deduct PAYG tax at a flat rate of _______% (Upward Variation attached)

BANK DETAILS:

To enable transfer of your payments directly into your nominated bank account, please provide exact details of you bank account here-under. If these details change in any way in the future, please contact us immediately. Changes must be made before 9am on a Thursday. Changes after 9am on a Thursday will not affect the current pay week. (Please note by law we cannot pay into your Credit Card Account.)

Name Of Bank:

Branch Location

Address Line 1

Address Line 2

City

State

Zip Code

ACCOUNT HOLDER:

BANK BSB NUMBER: (Must be six digits)

ACCOUNT NUMBER:

Signature

Date//

SUPERANNUATION:

Disclaimer: The section below is to enable you to provide clear instructions to Territory Disability Services. It is not financial advice and must not be construed as such. You should seek independent advice from your financial planner or accountant on your individual circumstances.

I understand that Territory Disability Services will make superannuation contributions at the current SG rate of 9.5%. This is in addition to my agreed pay rate. If you have a preferred Superannuation fund please provide details below. If you have no preferred fund we will make contributions into our nominated default fund

Please make a selection from OPTION 1 or OPTION 2.

TDS Staff member (Print name):

Signed:

Date changed in ACS://

GENERAL INFORMATION

FIRST CONTACT (IN CASE OF EMERGENCY)

Next of Kin:

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Relationship to you:

Mobile:

SECOND CONTACT (IN CASE OF EMERGENCY)

Next of Kin:

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Relationship to you:

Mobile:

CRIMINAL HISTORY

Have you ever been convicted of any criminal offence?

Are you prepared to have a criminal record check done?

HEALTH CARE REGISTRATION FORM

Personal Details

QUALIFICATIONS Please mark / list all education and qualifications (Documents will need to be provided before commencing work)

Registered Nurse (RN)

(RN & EN Must have valid Nursing Registration)

First Aid Certificate:

Working with Children Card (Ochre Card)

EXPERIENCE

AVAILABILITY

Workers Compensation

Employment Agency:

I authorise Territory Disability Services to:

*Obtain information about my capacity, conduct and performance from any previous employer or work site.

*Provide relevant information to a client business of Centre Labour Force

COMPETENCY CHECK

Hoist

PROCEDURE KNOWLEDGE

INDIVIDUAL EXPERIENCE

CONTRACTOR ACKNOWLEDGEMENT

I acknowledge that I have attended:

1. The Odco Contracting® system interview and explanation session: I understand my status as an independent contractor and have had the taxation, superannuation and insurance obligations explained to me.

INDUCTION PRESENTER

I confirm that I have delivered Territory Disability Services Induction Program with above named contractor.

AGREEMENT TO CONTRACT

CONDITIONS OF CONTRACT

1. I acknowledge and agree that there is no relationship of employer / employee with TERRITORY DISABILITY SERVICES and that TERRITORY DISABILITY SERVICES does not guarantee me any work. I am self-employed and, as such, I am not bound to accept any work through TERRITORY DISABILITY SERVICES.

2. I hereby agree to work for an agreed amount per hour for actual on-site hours, or job price to be agreed.

3. I instruct TERRITORY DISABILITY SERVICES to make deductions under the PAYG system of taxation.

4. I hereby agree that I have no claims on TERRITORY DISABILITY SERVICES in respect of Holiday Pay, Long Service Leave, Sick Pay, or any similar payment.

5. I hereby agree that TERRITORY DISABILITY SERVICES has no responsibility or liability to me, except that I am guaranteed to be paid for actual on-site hours worked or agreed job price for work done.

9. Intellectual Property You acknowledge and agree that it is a condition of ODCO Contract that Territory Disability Services shall be the owner of all Intellectual Property Rights in everything created, generated or contributed to by you in the course of your employment:

• whether alone or in conjunction with others;

• whether during office hours or otherwise;

• irrespective of where the creation, generation or contribution took place;

• which:

o relates to the business or prospective business of Territory Disability Services; or

o was created, generated or contributed to using any equipment or facilities of Territory Disability Services

• any rights in respect of (a); and

• any application or right to apply for registration of any of (a).

This clause will survive the termination of your ODCO Contract, irrespective of the basis of the termination, and shall remain in full force and effect indefinitely

For the purpose of this clause:

(a) “Restraint Period” means the following periods after your employment ends (for any reason):

(b) 12 months, or if that is unenforceable;

(c) 6 months, or if that is unenforceable

(d) 3 months.

Restraint Area" means:

(a) Australia, or if that is unenforceable; (b) The State, Territory or jurisdiction in which you predominantly worked during the 12- month period prior to your employment ending.

You acknowledge and agree that:

GENERAL DEDUCTION & PAYMENT AUTHORITY

PUBLIC LIABILITY INSURANCE & WORKERS COMPENSATION: (compulsory – refer to Contractor Guide): I wish to participate in the group fund. □ Company rate will be deducted from Gross payments and administered for Public Liability and Workers compensation.

BANK DETAILS:

SUPERANNUATION:

Disclaimer: The section below is to enable you to provide clear instructions to Territory Disability Services. It is not financial advice and must not be construed as such. You should seek independent advice from your financial planner or accountant on your individual circumstances.

GENERAL INFORMATION

FIRST CONTACT (IN CASE OF EMERGENCY)

SECOND CONTACT (IN CASE OF EMERGENCY)

CRIMINAL HISTORY

WORKERS COMPENSATION HISTORY

If YES, please provide details:

Note: If you do not provide accurate information you may not be entitled to any compensation if the nature of the work aggravates a pre-existing injury, illness or disease.

CONTRACTOR CONFIDENTIALITY AGREEMENT

Signed at CLF

On Behalf of Territory Disability Services:

ODCO HEALTH CONTRACTOR QUESTIONNAIRE

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