ASSESSOR / MODERATORREGISTRATIONFORM

Type of Application

Assessor Registration
Moderator Registration

PERSONAL DETAILS

Title / First Names / Surname
SA ID No / Passport No / Citizenship

(Please attach certified copy)

Date of Birth / YYYY / MM / DD / Gender
RACE
AFRICAN / WHITE / COLOURED / OTHER / INDIAN
Disability / Y / N / Specify
Physical Address / Postal Address
City / City
Post Code / Phone / Code / Number / Post Code / Fax / Code / Number
E- mail / Fax / Code / Number / Cell / Code / Number

Language proficiency (P-Poor, A-Average, G-Good, E-Excellent)

/ Home Language / Other Language 1 / Other Language 2
Speak / P / A / G / E / P / A / G / E / P / A / G / E
Read / P / A / G / E / P / A / G / E / P / A / G / E
Write / P / A / G / E / P / A / G / E / P / A / G / E
Present Job Title

APPLICANT’S QUALIFICATIONS

Generic Assessor / Moderator Certificate Number (Please attach certified copy)
Qualifications Achieved
(Please attach certified copy)
FORMAL QUALIFICATIONS
PLEASE INDICATE YOUR (related, relevant) HIGHEST EDUCATION ATTAINMENT LEVELS TO DATE. PLEASE TICK THE MOST APPROPRIATE BELOW:
Less than Standard 8 (Grade 10) or equivalent / Standard 9 (Grade 11) or equivalent / Standard 10 (Matric or Grade 12) or equivalent / Post-Matric Diploma / Undergraduate degree
Post graduate degree / Other (Please specify):
(RELEVANT) WHAT IS YOUR HIGHEST FORMAL QUALIFICATION? PLEASE COMPLETE THE TABLE BELOW
Name of qualification (or certificate achieved where not a qualification) / Brief description of content / Institution where obtained / Duration of programme / Date obtained
RELEVANT OCCUPATIONAL EXPERIENCE
If you are applying to be a registered assessor, have you achieved the unit standard ‘plan and conduct the assessment of learning outcomes’ at Level 5 on the NQF? / Yes /No / Unit standards/ qualifications covered
If you are applying to beregistered moderators have you achieved the unit standard ‘moderate assessments’ at Level 6 on the NQF? / Yes/No / If yes, give your ETDP SETA endorsement number
If you are applying to be a registered moderator have you achieved the unit standard ‘design and develop assessments’ at Level 6 on the NQF? / Yes/No / If yes, give your ETDP SETA endorsement number(OPTIONAL)
Are you a subject matter expert in the W&RSETA sector? / Yes/No / If yes, state your highest relevant qualification/ level of competence demonstrated
For how many years have you been involved in education, training and development practices and/or assessment? / Number of years / In what capacity?(STATISTICAL INFORMATION)
PLEASE INDICATE WHAT UNIT STANDARDS YOU WILL BE ASSESSING (OR MODERATING ASSESSMENTS) AGAINST AND WHAT SUBJECT MATTER EXPERTISE YOU HAVE IN THIS REGARD.
Unit standard title / Unit standard number / Brief description of technical competence or subject matter expertise / Attached as per annexure

SECTOR ASSESSED (YEAR) (M&E)

MODERATOR REGISTRATION APPLICANTS ONLY: PLEASE INDICATE THE NUMBER OF LEARNERS TAUGHT /ASSESSED /MODERATIONS CONDUCTED AND AVERAGE HOURS SPENT
ACTIVITY / In a typical day / In a typical week / In a typical month / In a typical year
Hours
Spent / No of learners / Hours
Spent / No of learners / Hours
Spent / No of learners / Hours
Spent / No of learners
Learners Trained
Learners Supported
Learners assessed
Learner assessments moderated
Total
Hours / Total Days / Total
Hours / Total Days / Total
Hours / Total Days / Total Hours / Total Days
TOTAL
PLEASE ENSURE THE FOLLOWING DOCUMENTS ACCOMPANY YOUR APPLICATION FORM: IF ANY DOCUMENTS ARE NOT INCLUDED THE APPLICATION WILL BE SENT BACK
Please mark
Certified copy of ID / Yes / No
Certified copy of qualifications / Yes / No
Certified copies of relevant unit standards for assessor /moderator competence:
ETDP Statement of results OR
Letter from the accredited ETDP training provider / Yes / No
CV detailing work related experience in relation to the unit standards you want to assess /moderate / Yes / No
Signed code of conduct[1] for relevant registration / Yes / No

EMPLOYER / PROVIDER INFORMATION

Full Name of Employer /Provider
Postal Address
City
Post Code
Phone / Code / Number
DECLARATIONS
Applicant: I hereby declare that the above information is correct, valid and accurate, and that if I am registered as an assessor /moderator I commit myself to the W&RSETA code of conduct for assessors /moderators
Signature of applicant:
Date:
Employer or provider: I hereby endorse this application and declare that the information is correct, valid and accurate.
Signature of employer:
Date:
AUTHORISATION
Applicant’s Signature / Date of Application / YYYY / MM / DD

Return completed application form to: the relevant office

FREE STATE ,
First Floor ,
200 Nelson Mandela Building
Cnr Noble and Nelson Mandela St
Bloemfontein
Phone: 051 447 8443
Fax: 051 447 8629
Contact person:
Regional Manager: Emmanuel Letsie
/ GAUTENG SOUTH
Buildingnumber 18
Ground floor
Woodlands Office Park
Western Service Road
Woodmead
Phone: 011656 0085
Fax: 011 656 0194
Contact Person
QA( Acting):Wiya Mgobozi
/ EASTERN CAPE
Kingls Tourism Centre
1 Aquarium Road
Bearch Front
East London 5201
Phone: 043 722 3010
Fax: 043 722 3730
Contact person:
QA:Sihle Gogela
/ WESTERN CAPE
3rd Floor
Old Warehouse Building
Black River Park
Fir Road
Observatory
Phone: 021 442 6700
Fax: 021 442 6777
Contact person:
QA: Peter Cleophas

GAUTENG NORTH
Ground floor, Block B
1267 Pretorius Street
Hadefield Office Park
Hatfield
Pretoria
Phone: 012430 4930
Fax: 012430 4935
Contact Person:
QA:Sipho Khoza
/ KWAZULU NATAL
Office 102b
Clifton Place
19 Hurts Grove
Mustgrave
Durban
4001
Phone: 031 277 0500
Fax: 031201 0008
Contact Person:
Team leader: Lou Pillay
/ MPUMALANGA
PO Box 17717
Emalahleni
1035
Tel: (013) 690 1214
Fax: (013) 690 1190
Contact person:
QA/Coordinator: Charles Motlhaping

FOR OFFICE USE ONLY

Please mark whether the applicant has attached the documents for evaluation purposes. If not request outstanding documents.

Certified copy of Identity Document
Certified copies of Qualification
Copy of CV
Assessor / Moderator Certificate from ETDP accredited Provider
OR
Certified copy of ETDP Statement of Results
Signed Code of Conduct

CODE OF CONDUCT FOR W&RSETA ASSESSORS

I, the undersigned, am applying to become a registered W&RSETA assessor. I agree that, if my application is successful, I hereby commit myself to abide by the W&RSETA Code of Conduct in relation to all my work conducted as a W&RSETA Assessor. The Code of Conduct to which I agree is as follows:

  1. I will conduct my work as a W&RSETA Assessor with integrity, seeking at all times to create a positive environment for assessment and to take note of and respect the historical diversity of candidates’ cultural, linguistic and educational backgrounds.
  1. I will recuse myself from the process in such instances where any conflict of interest, such as a financial or family relationship or close friendship is in existence between any candidate and myself. This information will be declared to the W&RSETA ETQA in advance.
  1. I will treat all information received during my work as a an assessor about individuals or organisations with the strictest confidentiality unless it is relevant to the fairness, reliability and validity of the assessment process;
  1. I will inform the W&RSETA about any relevant information about any irregularities in the assessment process of which I become aware ; these will include:
  1. suspected or proven irregularities committed by the candidate;
  2. suspected or proven irregularities committed by any other parties to the assessment;
  3. any suspected or proven bribery, threats or sexual or other harassment of or by candidates;
  4. any grounds for doubting the authenticity of the evidence presented during the assessment process.
  5. unplanned environmental, personal or other problems which may haveinterfered in the performance of the candidate
  1. I will draw all irregularities to the attention of the W&RSETA ETQA if I have reason to believe the provider and/or moderator is not addressing irregularities brought by myself to his or her notice.
  1. I will collate any constructive comments about the standards or qualifications that I receive from moderators or other parties involved in the assessment process and forward to the W&RSETA ETQA. These will be forwarded to the relevant SGB for inclusion in the SAQA review process.
  1. I will conduct my work in line with the vision and mission of the W&RSETA, particularly in relation to improving the quality of education, training and assessment for learners in the sector, assisting in creating a learning environment in which all learners are given opportunities to achieve their full potential.

Name in full (printed): ______Signed: ______

Date: ______

CODE OF CONDUCT FOR W&RSETA MODERATORS

I, the undersigned, am applying to become a registered W&RSETA moderator. I agree that, if my application is successful, I hereby commit myself to abide by the W&RSETA Code of Conduct in relation to all my work conducted as a W&RSETA moderator. I agree as follows:

  1. I will conduct my work as a W&RSETA moderator with integrity, seeking at all times to create a positive environment for assessment and to take note of and respect the historical diversity of candidates’ cultural, linguistic and educational backgrounds.
  1. I will recuse myself from the process in such instances where any conflict of interest, such as a financial or family relationship or close friendship is in existence between any candidate and myself. This information will be declared to the W&RSETA ETQA in advance.
  1. I will treat all information received during my work as a an assessor about individuals or organisations with the strictest confidentiality unless it is relevant to the fairness, reliability and validity of the assessment process;
  1. I will inform the W&RSETA ETQA and ask them to take appropriate steps if I identify a particular assessor who is unreliable.
  1. I will inform the W&RSETA about any relevant information about any irregularities in the assessment process of which I become aware ; these will include:
  1. suspected or proven irregularities committed by the candidate;
  2. suspected or proven irregularities committed by any other parties to the assessment;
  3. any suspected or proven bribery, threats or sexual or other harassment of or by candidates or assessor;
  4. any grounds for doubting the authenticity of the evidence presented during the assessment process.
  5. unplanned environmental, personal or other problems which may have interfered in the performance of the candidate
  1. I will provide any constructive comments about the assessment guides, learner guides, workplace guides, facilitator guides, process, procedure or tools utilised in the assessment process, these comments will be collated and put in my report to the W&RSETA ETQA. This feedback will be utilized to improve old guides and instruments and in the development of new ones in a continuing process of renewal and improvement of quality.
  1. I will conduct my work in line with the vision and mission of the W&RSETA, particularly in relation to improving the quality of education, training and assessment for learners and assessors in the sector, assisting in creating a learning environment in which all learners and assessors are given opportunities, guidance and support in achieving their full potential.

Name in full (printed): ______Signed: ______

Date: ______

Document Title / Assessor/ModeratorRegistration Form
Document Number / EAR003 / Date Compiled / June 2012
Page Number / Page 1 of 9 / Revision Date / June 2013
Revision Number / Rev 03 / Access / Controlled
Review:ETQA Manager / Approved:

[1] As per page 6 and or 7 of this document