2016-17 Jobs First STL Projects
Participant Commencement Form
To be completed by the Service Provider
Course Name: _______________________________________________________________________
DSD Project ID: ____________________
This project is fully or partially funded by the State Government of South Australia. Participating in this project represents an
agreement to provide the Department of State Development with information relating to your educational, employment history and
future contact. The information you provide will remain confidential.
First Name/s:
________________________________ Last Name: ______________________________________
Date of Birth:
_______ /_______ /_______
Please provide an email address and at least one phone number:
Email: ________________________________________ Mobile: _________________________________
1.
Do you identify as Aboriginal or Torres Strait Islander?
Yes
No
2.
Do you identify yourself as having 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)
3.
What is the highest level of school education you have completed? (tick one box)
Year 12 or equivalent
Still attending school
Year 11 or equivalent
Finished primary school but did not attend secondary school
Year 10
Attended primary school but did not finish
Year 9
Did not go to school
Year 8
4.
What is the highest level of post school education you have completed? (tick one box)
Not completed post school education
Diploma (or Associate Diploma)
Certificate I
Advanced Diploma or Associate Degree
Certificate II
Bachelor or higher Degree
Certificate III (or trade certificate)
Other, please specify: _____________________
Certificate IV (or advanced certificate)
5.
Of the following categories, which best describes your current employment status? (tick one box)
Working
Not Working
full time employee (working 35 hours or more on average per week)
unemployed; seeking full time work
part time employee (working under 35 hours on average per week)
unemployed; seeking part time work
self-employed; not employing others
not employed; not seeking employment
self-employed; employing others
unpaid worker in a family business
If not working, please skip to question 7.
Jobs First STL 2016-17_Participant Commencement and Consent Form_v1.0 , September 2016
6.
If you are currently working, please answer the following questions about your employment:
a)
Is your employment:
Casual
Contract
Permanent Part time
Traineeship/Apprenticeship
Permanent Full time
b)
How many hours on average do you work each week? ___________ hours per week
c)
Are you at risk of redundancy?
Yes
No
If working, please skip to question 8.
7.
If you are currently not working, 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
8.
Are you registered with Centrelink?
Yes
No
9.
Are you registered with a jobactive provider?
Yes
No
If yes:
a) What is the name of your provider?
b)
_________________________________________
In what stream have you been placed?
Stream A
10. Are you registered with a Disability Service Provider?
If yes:
a) What is the name of your provider?
Yes
Stream C
No
_________________________________________
11. Are you registered with a Community Development Program provider?
If yes:
a) What is the name of your provider?
Stream B
Yes
No
_________________________________________
To complete your enrolment in this project, please read and sign the Collection and Use of Personal Information form
overleaf.
Jobs First STL 2016-17_Participant Commencement and Consent Form_v1.0 , September 2016
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Participant Agreement
Collection and Use of Personal Information
I __________________________________________________________________________________
(First Name
Middle Name
Last Name)
of _________________________________________________________________________________
___________________________________________________________________________________
(Current residential OR postal address)
Date of Birth: ______/______/______, acknowledge and agree that:
1. I wish to participate in an activity funded by the Skills and Employment Division in the Department of State
Development.
2. I accept that the Minister for Employment, Higher Education and Skills (Minister) will allocate to me a
Participant Number, to be used to record my participation in, and the results of, activities funded by the
Skills and Employment Division in the Department of State Development.
3. I accept that the assessment as to whether I am eligible to participate in any specific activity funded by the
Skills and Employment Division in the Department of State Development will be undertaken by a service
provider who has an Employment Services Projects Agreement (EPSA) and/or Accredited Training
Services Agreement (ATSA) with the Minister for the delivery of the activity.
4. I consent to the Minister, its employees, agents and contractors collecting from the service provider my
results for all courses in which I have been enrolled, and using this information for the purpose of
determining whether I am eligible to enrol in an activity funded by the Skills and Employment Division in the
Department of State Development. I consent to the Minister, its employees, agents and contractors using
this information for the Department of State Development’s performance measurement and reporting
activities.
5. I consent to the Minister, its employees, agents and contractors collecting and using any student identifier
(as that term is defined in the Student Identifiers Act 2014) assigned to or relating to me and using that
student identifier to obtain transcripts and other information relating to me and using this information to
determine my eligibility for an activity funded by the Skills and Employment Division in the Department of
State Development and to record and track my progress through the activities funded by the Skills and
Employment Division in the Department of State Development.
6. I accept and agree that the Minister, its employees, agents and contractors will be in receipt of my
Personal Information and that they may be required to share my personal information with:

service providers who have a current contract with the Minister for the delivery of WorkReady activity;

other South Australian government agencies (including regulators) responsible and / or involved in
training and education (whether accredited or not), including but not limited to funding, monitoring
training and / or compliance;

Commonwealth government agencies (including regulators) responsible and / or involved in training
and education (whether accredited or not), including but not limited to policy, development, funding,
monitoring and / or compliance; and
Government agencies (including regulators) in other Australian states and territories responsible and /
or involved in the training and education (whether accredited or not), including but not limited to policy,
development, funding, monitoring and / or compliance.

7. By providing my Personal Information as outlined above, I am consenting to the Minister, its employees,
agents and contractors contacting me during or after I have ceased my participation in activities funded by
the Department of State Development for the purposes of:

statistical reporting and analysis in respect to the outcomes of the activity
Jobs First STL 2016-17_Participant Commencement and Consent Form_v1.0 , September 2016
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
undertaking an evaluation of the activity

promoting the activity and WorkReady (or any other programs run by the Minister which relates to
training and employment services);

assessing quality of training activity

recording the information about my training and other services provided

reporting on the WorkReady Program (or any other program run by the Minister which relates to
training and employment services).
8. I agree to notify the service provider if the Personal Information outlined above changes throughout the
duration of the project.
9. Where required by the Minister, I agree to access my participant profile maintained by the Minister and its
employees, agents and contractors and advise if any of the Personal Information contained in my student
profile is incorrect.
10. I agree to participate in data collection activities (including surveys, workshops, focus groups and other
methods of collecting information from participants) conducted by the Department of State Development to
evaluate skills and employment programs.
I hereby consent to the collection and use of my Personal Information in the manner outlined above.
Print full name: ______________________________________________________________________
Signature: _______________________________________________
Date: ______/______/______
Note: If the Participant is under 18 years of age at the time of signing, then the consent of their guardian is required.
Print full name of guardian: ___________________________________________________________
Signature: _______________________________________________
Date: ______/______/______
Thank you for completing this form. Please return it to the person who provided it to you. If you have any questions, please
contact the WorkReady Infoline on 1800 506 266.
To be completed by the Project Provider
I have discussed the above consent for collection and use of Personal Information and have verified the eligibility
requirements with:
Participant full name:
______________________________________________________________________
WorkReady Participant Number:
________________________________________
If the project is delivering accredited or non-accredited training:
Internal Unique ID OR STELA ID:
________________________________________
The Collection and Use of Personal Information Form must be forwarded to the Minister as per the timeframe
specified in the EPSA. You must retain this hard copy for your records.
Provider Declaration
Verified by:
Full name:
________________________________________________________________________________
Organisation: ________________________________________________________________________________
DSD Project ID:
____________________________________________
Signature: ________________________________________________________
Date: ______/______/______
Jobs First STL 2016-17_Participant Commencement and Consent Form_v1.0 , September 2016
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