PERSONAL DETAILS

PRIVATE & CONFIDENTIAL

Complete information as necessary

Title: Mr Name: Juan Fernando Ortiz
Address: Unit 701-238 Flinders Street
E-Mail (all payslips sent here): juanfdortiz@yahoo.fr D.O.B:23/05/1980
Phone (home): Phone (mobile): 0424207301

Emergency contact
Name: Andrea Ortiz Phone (work):
Phone (home): Phone (mobile): 0416036742

Bank
Account Name: Tax file number or ABN:
Address:
Name of bank Commonwealth Bank
BSB: Bank Account number:1206 5842

Superannuation Fund
Name and Account number:

Driving and plant equipment Licence (photocopy must be provided)

Details:

Other

Employee signature: Date: / /

FOR OFFICE USE ONLY:

Employee record completed  Yes  No
Pay rate:
Award:
 STAFF INDUCTION

BDK Worker Placement Details

Surname: Ortiz Ricaurte First name(s): Juan Fernando

Company where worker placed: BDK

Site address:

Department/division assigned to:

Proposed Job Title:

Department Manager:

Inductor:

Date Commenced:

Worker requested by who from client (name):

Inductee Item Checklist

Inductor and Worker to initial when each item is completed Inductor Worker

Completed Company WHS Induction  Yes  N/A

Shown the location of first aid facilities and first aid

attendants - compulsory  Yes  N/A

Shown the fire extinguisher location in work area -

compulsory  Yes  N/A

Site Evacuation Procedures explained – compulsory  Yes  N/A

 Assembly Point and Evacuation Route

Shown kitchen amenities, toilets and drinking water  Yes  N/A

Owns protective equipment/safety gear (PPE)  Yes  N/A

 Steel cap boots/shoes  Yes  N/A

 Industrial shirt/pants  Yes  N/A

 Hard hat  Yes  N/A

 Gloves  Yes  N/A

 Reflective vest  Yes  N/A

 Safety glasses  Yes  N/A

 Other:  Yes  N/A

Inductee Item Checklist continued

Initial Introduction to immediate work environment  Yes  N/A

Introduction to WHS Management System completed  Yes  N/A

Induction to Safe Work Method Statements relevant

to workload  Yes  N/A

Inductee introduced to:

Site Manager  Yes  N/A

 Supervisors  Yes  N/A

Site specific hazards and risk assessments explained  Yes  N/A

Hazardous substances locations and procedures  Yes  N/A

(storage, spills, SDS, etc.)

Initial on-the-job training for daily routine organized  Yes  N/A

with client - compulsory

Machinery Safety – explain specific requirements  Yes  N/A

Tour of work site provided and rules explained  Yes  N/A

Accident/incident/near miss reporting procedures  Yes  N/A

explained – compulsory

Is any specialized equipment required and has the  Yes  N/A

inductee been trained to use this equipment
The site Non Smoking/Smoking Policy explained –  Yes  N/A
compulsory

Has a site induction card been issued  Yes  N/A

This induction checklist must accompany the new employee during the site induction process.

Declaration

I acknowledge that I, the undersigned, have been advised on all of the above listed items and
understand the points discussed. Where appropriate, I also undertake to use and have been
instructed in the correct usage of Personal Protective Equipment (PPE). I accept that compliance to
safe work practices is a condition of my continued access to the site and also a requirement under
the WHS legislation.

The inductor has reiterated the key points of this induction program and I understand the procedures
involved.

Workers Name (Please print) Signature Date

Inductor’s Name (Please print) Signature Date

HEALTH QUESTIONNAIRE
PRIVATE & CONFIDENTIAL

Phone number:o424107301
First and last name: Juan Fernando Ortiz
Date: / /
Position offered:
(subject to satisfactory health checks)

If the answer is yes to any of the questions on this form, please give full details in the space provided
of the dates, duration and outcome of the illness or condition. If we have any concerns about your
fitness for work, employment will be subject to satisfactory medical reports.

Have you ever had Insert Yes/No Additional information to “Yes” response

Tuberculosis, asthma, bronchitis or

chest problems? No

Chest pain, heart condition or

raised blood pressure? No

Blackouts, fits or attacks of

giddiness? No

Depression, mental illness or

nervous breakdown? No

Rheumatism or arthritis? No

Back trouble? No

Typhoid or paratyphoid? No

Digestive or bowel disease? No

No
Diabetes, thyroid or other gland
trouble?

Bladder or kidney trouble? No

Dermatitis or skin trouble? No

Varicose veins? No
Have you ever had Insert Yes/No Additional information to “Yes” response

Any other accident, operation or

illness? No

Have you any reason to believe

you may be infected with any
communicable disease? No

Any other current or recent medical

condition or treatment which might
affect your attendance or
performance at work? No

Do you intend to work night duties

on a regular basis? No

Has any illness or medical

condition prevented you from
attending work on your normal
duties or activities for more than
one week during the past year? If
yes, please specify. No

Do you have any physical or

mental impairment which has a
substantial and long term effect on
your ability to carry out day to day
activities? If yes, please specify
any special adjustments required
in relation to work. No

Do you smoke? No

How many units of alcohol do you

drink per week?
(one unit = 1 middy beer =
1 glass wine = 1 shot of spirits) No
INDUCTION CHECKLIST

PRIVATE & CONFIDENTIAL

Date joined: /
Name: /

I have supplied the following documentation and information (tick as applicable)

 Tax file declaration

 Choice of super form

 Bank details (incl. bank, BSB, account #)

 Emergency contact details (incl. name, address, phone #, relationship)

 Driver’s licence

 Passport

 Visa (if applicable)

The following policies and details have been explained to me (tick as

applicable)

 Hours of work, including time recording, breaks etc.

 Layout of premises, including fire exits, first aid facilities

 Introduction to colleagues

 Facilities including toilets, kitchen facilities

 Employee handbook

 Fair Work Information Statement

**I Acknowledge that if I have not provided the above information my

wages may be delayed until such a time as provided**

Signature: Date: / /
Terms and Conditions for Employment

1/ I understand that employment is in accordance with the Award registered Industrial

Agreement governing the employer’s work.

2/ I agree and am prepared to wear any clothing, footwear or safety equipment that may be
supplied by the Company and agree to abide by all safety and work regulations / instructions.

3/ Company policy is that no alcohol is to be consumed between the commencement hours

and finishing hours on any working day, including the times designated as unpaid meal breaks.

4 / I understand that I am employed on a casual / full time / part time basis with the first six
months of employment on a probationary period.

5 / BDK Group Pty Ltd have the right to dismiss an employee without notice for conduct that
justifies instant dismissal. Instant dismissal does not require BDK to give notice, counselling or
warning if the employee is found to have committed serious and wilful misconduct. Serious and
or wilful misconduct includes but is not limited to : theft, consumption or possession of alcohol
or non prescribed drugs on any of BDK client’s premises, physical assault or harassment.

6 / Abandonment of Employment: If you fail to attend work without notifying the company of
reasons for your absence and expected duration of the absence , the company may treat your
absence as a resignation , in which case your employment with the company is terminated
without notice.

To the best of my knowledge, information supplied is accurate and true. I note that my
employment may be terminated if any statement is found to be false. I understand that I am to
be employed initially on a six month trial basis and that during the six month trial my
employment may be terminated with one week notice, if my work performance is
unsatisfactory or I am deemed unsuitable or unskilled for the job.

Applicants signature: Date: