We value your feedback to help us improve our services

Please note the following:

• The information provided on this form will be used by Perth Day Hospital (PDH) to evaluate your application.
• All data collected will be stored securely in the PDH database and may be subject to audits.
• The information will only be used for the purpose stated above and will not be disclosed for any other reasons.
• Perth Day Hospital adheres to both Federal and State Privacy Legislation, including compliance with the National Privacy Principles.
• A copy of the Perth Day Hospital Privacy Policy is available upon request

Personal & Contact Details

Submission Instructions:

• This form will be submitted directly via secure link to the Director Of Nursing
• Note – the submit button need to be linked to the secure website email

Please note the following:

• The information provided on this form will be used by Perth Day Hospital (PDH) to evaluate your application.
• All data collected will be stored securely in the PDH database and may be subject to audits.
• The information will only be used for the purpose stated above and will not be disclosed for any other reasons.
• Perth Day Hospital adheres to both Federal and State Privacy Legislation, including compliance with the National Privacy Principles. A copy of the Perth Day Hospital Privacy Policy is available upon request.

Personal & contact details

Employment History

Nursing Position

Skills & Qualifications

Professional References

REFERREE 1

REFERREE 2

Are you eligible to work in Australia

Documentation list for new employees

upload with application or send to [email protected]

Authorisation, Agreements and Declaration

• I Authorise Perth Day Hospital to complete a range of enquiries to assess my suitability for appointment including: a. Obtaining information about my past experience , performance and current fitness to practice from my nominated referees; b. Verifying information relevant to my application from the AHPRA and any other authority that regulates health practitioners
• I hereby declare that the information contained in this application is true and correct in every respect:

Please not following

• The information provided on this form will be used by Perth Day Hospital (PDH) to evaluate your application.
• All data collected will be stored securely in the PDH database and may be subject to audits.
• The information will only be used for the purpose stated above and will not be disclosed for any other reasons.
• Perth Day Hospital adheres to both Federal and State Privacy Legislation, including compliance with the National Privacy Principles.
• A copy of the Perth Day Hospital Privacy Policy is available upon request.

Personal & Contact Details

Address: (please complete preferred address for correspondence)

Phone:

Nomination Of Alternative Contact:

In the event of a clinical emergency, I authorise the following individual to be contacted if I am unavailable:

Qualifications – Undergraduate & Postgraduate

(Please attach any relevant supporting documentation)

Disclosure:

Please respond to each of the questions below by ticking the appropriate box. If you answered yes to any of the questions below, please attach a statement including details, dates and any relevant documentation.

Declaration

• I confirm the information provided is accurate, complete, and not misleading.
• I will notify Perth Day Hospital of any changes to my registration, contact details, or ability to practice.
• I agree to abide by Perth Day Hospital’s By-Laws and participate in required programs and quality improvement activities.

Checklist of Documentation Required:

Upload with application or email to [email protected]

Please note the following:

• The information provided on this form will be used by Perth Day Hospital (PDH) to evaluate your application.
• All data collected will be stored securely in the PDH database and may be subject to audits.
• The information will only be used for the purpose stated above and will not be disclosed for any other reasons.
• Perth Day Hospital adheres to both Federal and State Privacy Legislation, including compliance with the National Privacy Principles.
• A copy of the Perth Day Hospital Privacy Policy is available upon request

Personal & Contact Details

Address: (please complete preferred address for correspondence)

Phone:

Scope of Practice:

Nomination of Alternative Contact:

Referee 1:

Referee 2:

Qualifications – Undergraduate & Postgraduate

(Please attach any relevant supporting documentation)

Current Appointments

Disclosure:

Please respond to each of the questions below by ticking the appropriate box. If you answered yes to any of the questions below, please attach a statement including details, dates and any relevant documentation.

Declaration

• I warrant and represent that information provided by me to Perth Day Hospital in this application and in connection with the application is accurate and complete and is not misleading or deceiving or likely to mislead or deceive.
• I understand that if I have provided misleading or deceptive information or information which is likely to mislead or deceive, Perth Day Hospital Management may (in its absolute discretion) consider that I do not have ‘current fitness’ under the Hospital By–Laws.
• I agree that I will notify the Medical Director or CEO of any of the following
  • I develop a condition which would affect my ability to safely provide care
  • Any changes to my registration with AHPRA, including current or new undertakings, conditions, endorsements, dsuspension, reprimands or notations imposed.
  • A restriction, withdrawal or altercation to my appointment at another health care facility is imposed
  • I am convicted or charged with an indictable offense.
  • Changes to my contact details
• I acknowledge that I have been provided with, and read a copy of the Hospital By-Laws and will at all times abide by such By-Laws and any amendments. I agree to participate in the National Hand Hygiene Program and abide by all policies including Open Disclosure, Admission Inclusion/Exclusion Criteria, Patient Centred Care, Partnering with Consumers, and Infection Control Standards. Additionally, I am prepared to participate in teaching, and quality improvement activities of Perth Day Private Hospital.

Checklist of Documentation Required:

Upload with application or email to [email protected]

Evidence of completion of: