XX SCHOOL GOVERNING COUNCIL
PRE-EMPLOYMENT AND VOLUNTEER DECLARATION CHECKLIST
In order to be considered for employment/volunteering in the (insert name of school) School
governing council Out of school hours care (OSHC)/ Vacation care service, you must complete
all components of this declaration, including by providing additional information, supporting
information and documentation where necessary. You will not be considered for
employment/volunteering unless you complete the declaration and provide comprehensive and
complete information as necessary.
The school governing council has no obligation to contact you should you submit an incomplete
Declaration. If you have any questions about the Declaration and/or as to supporting
information, please contact (insert relevant contact person and contact details).
Any incorrect or misleading statement or information included in your application for
employment or this declaration, may lead to your application for employment being declined. In
the event that you include incorrect or misleading statements or information in your application
for employment or this declaration and you are employed, this will amount to misconduct and
will render you liable for disciplinary action including dismissal from employment.
The information provided on this pre-employment declaration will be checked with the relevant
authorities and sources. The information will be treated as confidential and dealt with in
accordance with the State Records Act 1997, the destruction schedules issued under that Act.
Personal Details: __
Applying for employment
OR
Volunteering
Title: Mr. Mrs. Ms. Miss. Dr. Prof. Other: _______________________________________________
Family name: _____________________
First name: ___________________________________
Middle name/s: ___________________
Date of birth: __________________________________
Any former name/s_________________
Preferred name: _______________________________
Country of birth: _____________________________
Languages other than English spoken: _________________________________________________
Are you Aboriginal or Torres Strait Islander? ____________________________________________
Gender: __________________________
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Document last updated: 23 October 2015
Residential address: __________________________________________________________________
___________________________________________________________________________________
Phone – home: ____________________
Phone – mobile: _________________________________
Email: _____________________________________________________________________________
Postal address (if different from above):
___________________________________________________________________________________
___________________________________________________________________________________
Emergency contact details: ____________________________________________________________
___________________________________________________________________________________
Qualification/s: ______________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
(Note – the original parchment/s must be sighted prior to employment)
Site use only
Parchment Sighted by
First Name
School governing council member
Position Title
Family Name
/
/
Date sighted
Current and previous employer or volunteering organisation: ________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Contact details (name / contact number) of 3 referees, including your current or most recent line
manager:
1.
2.
3.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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Document last updated: 23 October 2015
A relevant history assessment performed through the Department of Communities and Social
Inclusion must be provided (Please provide an original clearance to be sighted prior to employment):
Do you have a current clearance through DCSI?
YES / NO
Site use only
Clearance sighted by
First Name
Family Name
School governing council member
Position Title
Clearance expiry date
/
/
/
Date sighted
/
The school governing council may require an applicant to submit to further criminal history and
other screening by DCSI prior to the applicant being considered for employment despite the fact that
the applicant has an unexpired DCSI clearance.
Completion of Responding to abuse and neglect - education and care (RAN-EC) training or volunteer
induction must be completed prior to employment.
Have you completed RAN-EC training?
YES / NO Date: ________________________________
(Please provide an original certificate of training to be sighted prior to employment/volunteering)
Site use only
Certificate sighted by
First Name
Family Name
School governing council member
Position Title
Expiry date
/
/
/
Date sighted
/
1.
Have you ever been investigated, arrested, reported for or pleaded or been found guilty of
any criminal offence, including any traffic offences?
YES - NO
2.
Have you ever been the subject of allegations of conduct by you of a sexual nature towards or YES - NO
in relation to a child or children (person under 18 years of age) or an adult (person over 18
years of age) whom you were responsible for providing education/care or other services to?
3.
Have you ever been the subject of allegations or an investigation or any other process
relating to alleged unsatisfactory performance or misconduct by you as an employee?
YES - NO
4.
Do you consent to and agree to facilitate an approved criminal history screening during
the course of your employment (if you are employed) at the discretion of the school
governing council?
YES - NO
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5.
Do you suffer from or have you ever suffered from any medical condition/s, illness/es,
disability/ies, restriction/s, or any learning disability/s that may affect your ability to carry
out the duties of the role you apply for?
YES - NO
6.
Are you taking or consuming any prescription medication/s or other substance/s that may
affect your ability to perform the duties of the role applied for or give rise to a risk to your
health or safety in the workplace or that of other persons?
YES - NO
7.
Have you been dismissed from any previous employment for any reason (including but not
limited to redundancy)?
YES - NO
Instructions:
If you answered ‘yes’ to any of the above questions, you are obliged to provide comprehensive
supporting details, including any relevant documentation in order to be considered for
employment.
In the event any further medical information is required, you may be invited to provide a
representative of the governing council with authority to seek medical information from any
treating medical practitioner/s or from an independent medical practitioner/s. You may be
personally liable for any cost associated with ascertaining any further medical information.
I confirm and declare that to the best of my knowledge, I have truthfully answered all questions
in this Declaration and provided any supporting information required.
YES - NO
I understand that should my circumstances change such that any information provided in or
with respect to this Declaration is materially different, it is my responsibility to advise the
governing council, within 24 hours of the detail of such changed circumstances.
YES - NO
I understand that any false or materially misleading information I provide will result in me not
being considered for employment or, in the event that I am offered and accept employment,
may render me liable for disciplinary action, which may include termination of employment.
YES - NO
Signature: __________________________________________
Date: _______________________________________________

Please provide the school governing council representative copies of all originals
sighted to be attached to the pre-employment declaration.
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Document last updated: 23 October 2015