Fillable Declaration Pre-employment of this declaration, including by providing (Services Australia)

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Declaration Pre-employment of this declaration, including by providing (Services Australia)

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The Declaration Pre-employment of this declaration, including by providing (Services Australia) form is 4 pages long and contains:

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  • 10 check-boxes
  • 60 other fields

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File type: PDF

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VL233
Updated 04/19
Department for Education employees
please return to:
Courier R11/10
GPO Box 1152
Adelaide SA 5001
Residential
Address
State
Postcode
Person ID
(if you do not have
an ID number please leave blank.)
Date of Birth
Given
Name(s)
Family
Name
Title
(Mr, Mrs, Etc)
Telephone -
Home
Mobile
In order to be considered for employment in any capacity in the Department for Education, you must complete all components
of this declaration, including by providing additional, supporting information and documentation where a yes response has
been recorded. You will not be considered for employment unless you complete the declaration and provide comprehensive
and complete information as necessary.
Ocers of the department have no obligation to contact you should you submit an incomplete declaration or not attach
details as required. If you have any questions about the declaration and/or as to supporting information, please contact
the department.
The information provided will be treated as condential and dealt with in accordance with the State Records Act 1997,
the destruction schedules issued under that Act and the Cabinet Administrative Instruction 1/89 known as the Information
Privacy Principles.
Former Name/s
(if applicable)
Country of
Origin
Languages other
than English spoken
Gender
Postal Address
(if dierent from above)
Qualication 1 (attach documents if more than one)
Current Govt /
Private Agency
Pre-employment
Declaration
Section 1: EMPLOYEE DETAILS
Resident Status
(please tick):
Permanent Non Permanent (residency permit/work visa must be attached)
Are you of
(please tick):
Aboriginal Origin
Aboriginal and Torres Strait
Islander Origin
Torres Strait Islander Origin
Not Aboriginal and/or Torres
Strait Islander Origin
Unknown
Section 2: Qualication Details
Male
Female
Institution
Applicant Initial
Start Date:
End Date:
Are you currently permanent within
the SA govt:
Yes No
Government Only -
original start date
Email -
Personal
Section 4: Mandatory Certicates and Training
Copy Attached
Expiry Date
All Employees
Department of Human Services (DHS) – Working with Children Check
(WWCC)
All Employees
Responding to Abuse and Neglect - Education Care Online Training
Copy Attached
Expiry Date
Other
Section 3: Australian Residency
Attach a copy of your Australian birth certicate, passport or citizenship certicate, or visa and overseas birth certcate or
passport (legal name must match your Department of Human Services (DHS) – Working with Children Check (WWCC)
Section 5: Place a tick in the appropriate box below to answer the following:
VL233
Continued
PRE-EMPLOYMENT DECLARATION
To be eligible to receive an oer of employment within the South Australian public sector; including the Department for Education,
you must complete a pre-employment declaration. You may also be required to agree to other pre-employment processes.
Information in this declaration and other pre-employment processes is necessary to assess the suitability of applicants to be
oered employment in the South Australian public sector, having regard to an applicant’s ability to perform the technical aspects
of a role and in consideration of the ethical obligations on public sector employees.
Some information is necessary to seek to ensure the Crown and responsible ocers of the Crown comply with their obligations
under the Work Health and Safety Act 2012. Some information is to ensure public sector agencies meet workplace diversity
targets.
The information is collected and managed in accordance with the State Records Act 1997 and destruction schedules issued
under that Act, and the Cabinet Administrative Instruction 1/89 known as the Information Privacy Principles Instruction and
Premier and Cabinet Circular No. 12.
You should be aware that the denition of misconduct in the Public Sector Act 2009 includes providing a false statement in
connection with an application for engagement as a public sector employee.
MEDICAL AND/OR DISABILITY:
The following question is designed to assist in ensuring you are t to perform the duties of the role you have applied for; in
ascertaining if any reasonable workplace adjustments are required in order for you to perform the inherent requirements of the
role; and to assist the Crown and responsible ocers of the Crown in meeting obligations under the Work Health and Safety
Act 2012.
This question is also important to assist public sector agencies to implement workplace diversity initiatives.
Please Note: If yes or unsure, please provide details (include details of any medications/ assistance/ adjustments that may
reasonably be required so that you can perform the inherent requirements of the role):
Please note: you may be required to participate in a medical and/or functional capacity assessment (at your own cost) in order
to assist in assessing your suitability to be oered employment in the role and South Australian public sector.
If you do not agree to participate, you will not be further considered to receive an oer of employment
CRIMINAL HISTORY:
Public sector employees are under signicant ethical obligations. In assessing whether it is appropriate to oer you
employment in the South Australian public sector, it is important to consider your suitability to adhere with these ethical
obligations, your character, and prior conduct. The following questions are important to help assess your suitability to be
oered employment in the South Australian public sector.
2. Have you ever been investigated or found guilty of any criminal oence, including
any trac oences not resolved by expiation?
3. Have you ever been the subject of allegations of conduct by you towards a child
(Person under 18 years of age) that if proven would have amounted to criminal
conduct or would have constituted misconduct in an employment setting?
4. Are you currently facing criminal charges yet to be determined?
Please give further information if ‘Yes’ has been ticked
1. Do you currently have any medical condition or disability (including learning
disability) which might prevent or impede you from being able to satisfactorily
perform any duties or functions that might be reasonably required of you in the
role for which you have applied?
Yes No
Unsure
Yes No
Yes No
Yes
No
Applicant Initial
Section 6: Indicate with a tick that you have read and understood the following:
VL233
Continued
Please note:
In addition to this declaration, you may be asked to agree to Criminal History or other background history screening or assessment.
You will not be further considered for an oer of employment in the South Australian public sector if you do not agree to participate
in such history or other background screening or assessment.
If you are oered and accept employment in the South Australian public sector, it will be a condition of such employment that you
agree to periodic history or background screening or assessment.
EMPLOYMENT HISTORY:
The following questions are also designed to assist in assessing your suitability to be employed in the South Australian public
sector with regard to the signicant ethical obligations on public sector employees
5. Has your employment been terminated by any organisation, including a South
Australian public sector agency, for any reason?
6. Have you been the subject of allegations or an investigation or any other process
relating to alleged unsatisfactory performance or misconduct by you as an employee?
7. Are you currently, the subject of an investigation or any other process relating to
suspected or alleged misconduct or other unsatisfactory performance by you?
Please give further information if ‘Yes’ has been ticked
VOLUNTARY SEPARATION AND REDEMPTION OF WORKERS COMPENSATION ENTITLEMENTS:
8. Have you ever received any voluntary early retirement or voluntary separation package from
employment in the South Australian public sector, including accepting a ‘Change in
Direction’ or ‘Teacher Renewal’ incentive payment or ?
9. Have you resigned from employment in the South Australian Public Sector or private
employer upon the redemption of workers compensation entitlements?
Yes No
Yes No
Yes No
Yes
No
Yes
No
Applicant Initial
Commencement date of agreement
DECLARATION:
I declare that the information in this declaration and in any other documents completed by me and/or any other statement made
by me in support of my application for employment in the South Australian public sector, and the information provided by me in
connection with my application for employment in the South Australian public sector, including in any interview, is true and correct
in every detail.
DISCLOSURE OF CONFIDENTIAL INFORMATION
I acknowledge that if I am employed in the public sector either in the role for which I have been oered or in any other role, I
may, during the course of that employment, gain access to condential information. Detailed provisions regarding disclosure of
condential information are contained in relevant public sector legislation, regulations, determinations, guidelines and industrial
instruments. Without detracting from such sources, unless such information is clearly not of a condential nature, and unless I am
expressly advised to the contrary by someone with requisite authority, policy or as required by law all information I gain access to
as a public sector employee is to be treated as condential. The expression “condential information” as used in this declaration
means all information which must be treated as being of a condential nature. I understand that I must not disclose or make use
of that condential information, during or after that employment, except in the proper course of my duties and/or with requisite
authority and/or otherwise according to law. In particular, I undertake not to use any condential information gained by virtue of
any public sector employment, with the intent of securing a benet for myself, any person, company or any future employer. In any
case where I am in doubt as to whether information gained during employment in the South Australian public sector is condential
and/or how such information should be managed, I undertake to seek advice and instruction from a supervisor or manager.
POTENTIAL OR ACTUAL CONFLICT OF INTEREST
I undertake that if I am employed in the public sector either in the role for which I have been oered or in any other role, I will not
engage in any external or private activities which will result in a conict or potential conict of interest with any of my duties as
a public sector employee. I am aware that detailed provisions regarding conict of interest and disclosure of conict of interest
are contained in relevant public sector legislation, and guidelines. Without detracting from such sources, in any case where there
is any possible doubt regarding a potential conict of interest, I undertake to seek advice and instruction from a supervisor or
manager.
OFFICE USE ONLY – People and Culture Operations - Corporate
NOTE:
Under the Public Sector Act 2009, the denition of ‘misconduct’ includes making a false statement in connection with an application
for employment as a public sector employee.
Under regulation 8 of the Education Regulations 1997, applicants for employment in the teaching service under the Education Act
1972 must furnish true and complete information and truthfully answer all questions asked by the relevant authority. Where an
applicant furnishes any materially false or misleading information, they are guilty of an oence and liable to a penalty of up to one
hundred dollars.
EMPLOYMENT BASED ON PROVISION OF TRUE AND CORRECT INFORMATION
I understand that if I am oered employment in the public sector it has been made on the basis
that the information that I have provided in connection with my application for employment is true
and correct in every detail. I understand that any false statement made in connection with my
application for employment in the South Australian public sector - which will include information
withheld or incomplete - may lead to a rejection of my application for employment, or, in the event
that I am employed or continue employment in the South Australian public sector, will amount to
misconduct and render me liable to disciplinary action, including termination of employment.
Yes No
Signature
Date
Instructions VL233 Pre-employment Declaration – Internal Use Only
Personnel le commenced to include:
• Pre-employment Declaration VL233
• VL181 Scheduling / Appointment form
• Department of Human Services (DHS) Working with Children Check (WWCC) (must be in full legal name)
• Responding to Abuse and Neglect – Education and Care Certicate (if completed)
• Australian residency (Australian birth certicate, passport or Citizenship Certicate) or visa and overseas birth certcate or
passport
• Qualications
• Medical clearance (if applicable)
• Signed contract letter
Forward the following to the Recruitment Centre (Education.HRCondential@sa.gov.au) for verication in Valeo: Veried
• Pre-employment Declaration VL233 ............................................................................................................................
• Department of Human Services (DHS) Working with Children Check (WWCC) (must be in full legal name) ..............
• Responding to Abuse and Neglect – Education and Care Certicate (if completed) ...................................................
• Australian residency (Australian birth certicate, passport or Citizenship Certicate) or visa and overseas
birth certcate or passport ............................................................................................................................................
• Qualications ................................................................................................................................................................
• Medical clearance (if applicable) ..................................................................................................................................
Forward the following to Shared Services Payroll Team 05:
• Copy of Pre-employment Declaration VL233
• Copy of VL181 Scheduling / Appointment
• Bank Details form VL628
• Tax File Number Declaration form
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Declaration Pre-employment of this declaration, including by providing (Services Australia)

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Completed 19 April 2022

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