Regional Employment Fund

2014-15 Participant Commencement Form

(to be completed by the participant)

Project Name: Individual Employment

Thisproject is fully or partially funded by the State Government of South Australia. Participating in a Skills for Jobs in Regions project represents an agreement to provide the Department of State Developmentwith information relating to your educational and employment history. The information you provide will remain confidential. Please provide the following personal details and answer the questions below.

On what date did you commence this project? ______/______/______

Participant Details

First Names: _____________Last Name: ______

Postal Address: ______

Postal Suburb: ______Postcode: ______

If your street address is different from the address above, what suburb do you live in?

Physical Suburb: ______Postcode: ______

Email: ______

Phone:______Mobile:______

Gender: MaleFemale

Date of Birth:______/______/______Age at project commencement: ______

  1. Are you of Aboriginal or Torres Strait Islander origin? Yes No
  2. Do you consider yourself to have a disability?Yes No

(Includes any limitation, restriction or impairment which restricts everyday activities and has lasted or is likely to last for at least six months)

  1. Do you speak a language other than English at home? YesNo

If yes, what language is most often spoken?______

  1. Were you born outside of Australia? No Yes, please specify country:______

If yes, what year did you first arrive in Australia?______

  1. What is the highest level of school education you have completed? (tick one box)

Year 12 or equivalentStill attending school

Year 11 or equivalentFinished primary school but did not attend secondary school

Year 10Attended primary school but did not finish

Year 9Did not go to school

Year 8Not applicable

Please continue over the page

Project Details – Office Use Only

Grantee: City of Onkaparinga
Provider / Sub-contractor: City of Onkaparinga
DSD Project ID:2884
Project Start Date: 16 / 01 / 2015

Project Finish Date: 30 / 11 / 2015

/ DSD Use Only
Date checked:
Checked by:
  1. What is the highest level of post school education you have completed? (tick one box)

Certificate I Diploma (or Associate Diploma)

Certificate II Advanced Diploma or Associate Degree

Certificate III (or trade certificate) Bachelor or higher Degree

Certificate IV (or advanced certificate) Not Applicable

Certificate other than listed

7.Of the following categories which bestdescribes your current employment status?(tick one box)

Working
full time employee
part time employee (working less than 35 hours on average per week)
self-employed; not employing others
un-paid worker in family business
employer / Continue to question 9.
Not Working
unemployed; seeking full time work
unemployed; seeking part time work
not employed; not seeking employment / Continue to question 8.
  1. If un-employed, please answer the following questions:

a)Have you been unemployed for 12 months or longer?Yes No

b)Are you a retrenched worker?Yes No

  1. If employed, please answer the following questions about your employment:

a)Is your employment: CasualPermanent Part timePermanent Fulltime

ContractTraineeship/Apprenticeship

b)How many hourson average do you work each week?______hours per week

c)Do you consider yourself to be (tick one box if relevant):

Underemployed (working less than 35 hours per week but would prefer and able to work more hours)

At risk of redundancy or reduced employment

Seeking career advancement or a change in career

10.Are you registered with Centrelink?YesNo

a)If yes, what is your Centrelink Reference Number: ______

b)If yes, what payment type do you receive?

Parenting Payment SingleParenting Payment Partnered

Disability Support PensionNewstart Allowance

Youth AllowanceOther, please specify: ______

11.Are you registeredwith a:

a)Job Services Australia Provider?YesNo

If yes, in what stream have you been placed?

Stream 1Stream 2Stream 3Stream 4

b)Disability Employment Service Provider?YesNo

c)Remote Jobs and Communities Provider?Yes No

If yes, to any of the above, what is the name of your Provider?:

______

Consent for the collection and use of personal information

Information held by the Department of State Development (DSD) is subject to the ‘Information Privacy Principles’ issued by the South Australian Department of Premier and Cabinet. I understand that personal information that has been collected, used and stored will be dealt with by DSD in accordance with the relevant privacy guidelines.

I understand the meaning of this form and agree to the use of personal information as described above

Do you authorise the project provider(as identified on page 1) to contact your JSA or DES provider to share relevant information for the purpose of coordinating additional support that you may require while participating on this project? Yes No

Participant’s Signature______Date / /

Parent/Guardian Declaration
(if you are under 18 years of age at the time of giving consent, then the consent of your parent/guardian is required)
Full name of parent/guardian: ______
Parent/Guardian’s Signature______Date / /

Personal information held by DSD is subject to the ‘Information Privacy Principles’ issued by the South Australian Department of Premier and Cabinet and may only be use for the purpose in which it has been collected. “Personal Information” means information or an opinion (including or an opinion forming part of a database), whether true or not, and whether recorded in a material form or not, about an individual whose identify is apparent, or can reasonably be ascertained, from the information or opinion.

Thank you for filling in this form. Please return it to the person who provided it to you.

If you have any questions you are welcome to contact Employment Directorateon (08) 8463 6737.

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