CHC33015 Certificate III in Individual Support COURSE GUIDE FOR: ONLINE STUDENTS

Transcription

1 CHC33015 Certificate III in Individual Support COURSE GUIDE FOR: ONLINE STUDENTS

2 CONTENTS ROYAL REHAB COLLEGE 3 COURSE OUTLINE 3 CAREER OPPORTUNITIES 3 PROGRAM OVERVIEW 4 MODE OF DELIVERY 4 ASSESSMENT 4 RECOGNITION 5 ENTRY REQUIREMENTS 5 ENROLMENT PROCEDURE AND REQUIRED DOCUMENTATION 5 STUDY MATERIALS/TEXTBOOKS/OTHER INCLUSIONS 5 ON-THE-JOB TRAINING 6 AVENUES OF SUPPORT 6 STUDY WORKLOAD 7 STARTING DATES 7 COURSE STRUCTURE 7 CORE COMPETENCIES 8 ELECTIVE UNITS OF COMPETENCY 9 Ageing Stream 10 Disability Stream 11 Home and Community Stream 12 STAND ALONE ACCREDITED UNITS OF COMPETENCY 13 FEES/CHARGES/REFUNDS 14 OTHER COSTS 14 REFUNDS 15 WHAT HAPPENS NEXT? 15 CONTACTING THE COLLEGE 16 APPENDIX A EXAMPLE OF ROYAL REHAB HEALTH ASSESSMENT FOR EMPLOYEES AND WORK EXPERIENCE STUDENTS 17 Page 2 of 21

3 ROYAL REHAB COLLEGE Set in the grounds of the acclaimed Royal Rehabilitation Hospital at Ryde, our ultra-modern college delivers online and distance training using web links, videos, readings and course information as well as providing face to face tutorials with our Educators, who are all professionals in their field(s) of disability, ageing support, and home and community care. Students are able to study from home, blending their course work with their personal and working lives. Royal Rehab College has a friendly, experienced team who are ready to support you throughout your course from enrolment to graduation! Readily available support means that you do not feel isolated in your online studies with, access available to the team during business hours. This Course Guide is to be read in conjunction with the Student Handbook. The Student Handbook contains the policies, procedures and general information that apply to all of our nationally recognised training courses. COURSE OUTLINE Welcome to the CHC33015 Certificate III in Individual Support! One of our experienced college educators will be facilitating this course and marking your assessments. Either the Enrolments Coordinator or your educator will be in touch with you soon. We look forward to working with you, to achieve your qualification. The Certificate III in Individual Support is a nationally recognised qualification, with completion enabling students to work with people with disability or people who are ageing who have requested support. You will develop knowledge and understanding of disability, ageing, empowerment, communication, skills building, behaviour support and professional development. You will also develop knowledge of work health and safety, the legal requirements of services and their employees, and the ethical practice of your work. The focus will be on person-centred, rights based services. CAREER OPPORTUNITIES Staff who assist people with disability and older people work in a variety of settings, including the person s home, supported accommodation, day options programs, and supported employment. They may be employed in such positions as a Disability Support Worker, a Community Care Worker, an Assistant in Nursing, or a Lifestyle Support Worker. They generally work under the Page 3 of 21

4 supervision of a Manager. The role, regardless of the position or the venue, is to support the individual in the pursuit of their goals. PROGRAM OVERVIEW To receive the national qualification of CHC33015 Certificate III in Individual Support, you are required to successfully complete 13 units of competency: Seven (7) units are core units of competency And six (6) units are elective (to be chosen from a list provided) Enrol at any time, and study the Certificate III in Individual Support online, allowing you to work at your own pace. This approach means that you must find a suitable venue or employer in the community (this will be subject to Royal Rehab College approval), and undertake at least 120 hours of work placement over the time of your course, allowing you to gain the skills and knowledge required for you to complete your assessments. Most students are able to complete this course in approximately 12 months. You may be able to complete sooner if you are able to dedicate more time to your study. You have a maximum time of 15 months to complete (unless you are a trainee, in which case your course time frame will be determined by your Australian Apprenticeship Centre) If you withdraw before you complete the required number of units successfully, or you do not complete your course in the required timeframe, you will receive a Statement of Attainment for those units that you have successfully completed. MODE OF DELIVERY This program is delivered in a combination of on-the-job and off-the-job training and assessment. It combines self paced learning and work based learning. The self paced component is available online. ASSESSMENT All assessments are competency based. The types of assessments used include (but is not limited to) knowledge tests, third party on the job observations and case studies. Page 4 of 21

5 RECOGNITION If you already have training, work experience or relevant life experience in the disability/ageing support/home and community care areas, you may be eligible to have your skills and knowledge recognised, to attain Recognition of Prior Learning or Credit Transfer for one or more units of competency. Speak to the Enrolments Coordinator or your educator if you think this applies to you. ENTRY REQUIREMENTS You will need to show that you have adequate Language, Literacy and Numeracy skills to undertake the course and to support people with disability and people who are ageing. You will be required to take a basic short quiz during the enrolment process to show this. ENROLMENT PROCEDURE AND REQUIRED DOCUMENTATION The enrolment process and documentation needed are as follows: When you complete the Application for Enrolment form on the website, a member of the Royal Rehab College s enrolment team will contact you to take you through the procedure. Documentation required: A completed signed Application for Enrolment form Completed LLN test (as part of your application form enrolment) Certified copy of photo ID Your Unique Student Identifier (USI). Please see the instruction Fact Sheet on our website Certified copies of any previous qualifications and statements of attainment, for which you are seeking Credit/RPL Completed application for Credit/RPL (if applicable) Payment Options Form When you have provided all of this documentation, we can get you started! STUDY MATERIALS/TEXTBOOKS/OTHER INCLUSIONS You will be provided with the appropriate support materials that you will need to be able to complete the course. Page 5 of 21

6 ON-THE-JOB TRAINING The emphasis of this Certificate III course is on learning by doing. In the workplace this means you should use the work you are doing as a means of embedding your new learning and practising your skills. If you are not currently employed in the areas of disability or ageing support or home and community care, you will need to arrange work placement/experience or volunteer work with a suitable service for a total of at least 120 hours, in order to complete the on-the-job component of this course. Your placement must be approved by Royal Rehab College before you commence. There will be a Workplace Agreement on your Online Learning Platform that you will need to complete your section, before asking the workplace supervisor to complete their section. The form will then be sent into your Royal Rehab educator for approval. The on-the-job training will be conducted by your workplace supervisor/s. As part of your work placement, you may need to provide a number of things to the host organisation. The requirements will vary between organisations, but they could include: Police Check (compulsory) Working with Children Check Health Assessment (please Appendix A for an example of the Royal Rehab Health Assessment). You will be responsible for obtaining these, and also for any cost incurred. AVENUES OF SUPPORT Workplace Colleagues - You may wish to select a workplace colleague (peer) with whom you can talk about your training, and discuss work samples or situations that provide evidence of your existing or new skills. Educator - Your educator is able to assist you with any overall course-related issues or concerns by phone or . During the training you will have the opportunity to communicate with the educator who will your monitor progress through the course. Workplace Supervisor - Your supervisor can assist you with support and/or study requirements in the workplace. Page 6 of 21

7 STUDY WORKLOAD It is expected that you will complete this course within 15 months. Your assessments should be submitted as you complete each unit. Taking less time will depend on individual circumstances. You have up to 15 months from enrolment to complete the Certificate III in Individual Support. However, if you are having problems and foresee that you may not be able to complete in time, please speak to your educator about applying for a short extension. STARTING DATES You can enroll in the Certificate III in Individual Support at any time, and get started on your learning as soon as your first payment is received. COURSE STRUCTURE To successfully complete the Certificate III in Individual Support, you will need to complete: Core Units (7) Elective Units (6) You will be assessed in a number of different ways. The methods used will be a variety chosen from the list below: Short answer questions Case studies Projects Research Portfolios of evidence Third party reports (observation of your skills by your workplace supervisor) There are NO exams! Assessments will always come with substantial instructions, but if you need some help working out what needs to be done, please don t hesitate to contact us. Page 7 of 21

8 CORE COMPETENCIES All core units must be completed CHCCCS015 Provide individualised support This unit describes the skills and knowledge required to organise, provide and monitor support services within the limits established by an individualised plan. The individualised plan refers to the support or service provision plan developed for the individual accessing the service and may have many different names in different organisations. This unit applies to workers who provide support under direct or indirect supervision in any community services or health context. CHCCCS023 Support independence and wellbeing This unit describes the skills and knowledge required to provide individualised services in ways that support independence, as well as, physical and emotional wellbeing. This unit applies to workers in a range of community services contexts who provide frontline support services within the context of an established individualised plan. CHCCOM005 Communicate and work in health or community services This unit describes the skills and knowledge required to communicate effectively with clients, colleagues, management and other industry providers. This unit applies to a range of health and community service contexts where workers may communicate face-to-face, in writing or using digital media and work with limited responsibility under direct or indirect supervision. CHCDIV001 Work with diverse people This unit describes the skills and knowledge required to work respectfully with people from diverse social and cultural groups and situations, including Aboriginal and/or Torres Strait Islander people. This unit applies to all workers. CHCLEG001 Work legally and ethically This unit describes the skills and knowledge required to identify and work within the legal and ethical frameworks that apply to an individual job role. This unit applies to community services and health workers who play a proactive role in identifying and meeting their legal and ethical responsibilities. Page 8 of 21

9 HLTAAP001 Recognise health body systems This unit describes the skills and knowledge required to work with basic information about the human body and to recognise and promote ways to maintain healthy functioning of the body. This unit applies to any worker who needs to use and interpret information that includes references to client anatomy and physiology. HLTWHS002 Follow safe work practices for direct client care This unit describes the skills and knowledge required for a worker to participate in safe work practices to ensure their own health and safety, and that of others in work environments that involve caring directly for clients. It has a focus on maintaining safety of the worker, the people being supported and other community members. This unit applies to all workers who require knowledge of workplace health and safety (WHS) to carry out their own work, in both centre-based and home-based service provision. ELECTIVE UNITS OF COMPETENCY Students need to choose: 6 elective units, consisting of: at least 4 units from the electives listed below - at least 2 of those units must be from those units listed under Groups A, B or C up to 2 units from the electives listed below, from any endorsed Training Package or accredited course these units must be relevant to the work outcome Any combination of electives that meets the rules above can be selected for the award of the Certificate III in Individual Support. Where appropriate, electives may be packaged to provide a qualification with a specialisation. Packaging for each specialisation: All Group A electives must be selected for award of the Certificate III in Individual Support (Ageing). All Group B electives must be selected for award of the Certificate III in Individual Support (Disability). At least four units from Group C electives must be selected for award of the Certificate III in Individual Support (Home and Community). Where two specialisations are completed award of the qualification would read Certificate III in Individual Support (Ageing, Home and Community). All electives chosen must contribute to a valid, industry-supported vocational outcome. Page 9 of 21

10 Ageing Stream CHCAGE001 Facilitate the empowerment of older people This unit describes the skills and knowledge required to respond to the goals and aspirations of older people and provide support services in a manner that focuses on improving health outcomes and quality of life, using a person-centred approach. This unit applies to support workers in residential or community contexts. CHCAGE005 Provide support to people living with dementia This unit describes the skills and knowledge required to provide person-centred care and support to people living with dementia. It involves following and contributing to an established individual plan. This unit applies to workers in a residential or community context, including family homes. Work performed requires some discretion and judgement and may be carried out under regular direct or indirect supervision. CHCCCS011 Meet personal support needs This unit describes the skills and knowledge required to determine and respond to an individual s physical personal support needs and to support activities of daily living. This unit applies to workers who provide support to people according to an established individualised plan in any community services context. Work performed requires some discretion and judgement and may be carried out under regular direct or indirect supervision. HLTHPS006 Assist with medication This unit describes the skills and knowledge required to prepare for and provide medication assistance, and complete medication documentation. It also involves supporting a client to selfadminister medication. This unit applies to community services and health workers with authority in their state or territory to assist with the administration of medication. CHCHCS001 Provide home and community support services This unit describes the skills and knowledge required to work in a home support environment and community settings with individuals, family members, staff, visitors, suppliers and others to meet established work requirements. This unit applies to workers in a community services context. Work performed requires some discretion and judgement and is carried out under regular direct or indirect supervision. Page 10 of 21

11 CHCCCS025 Support relationships with carers and families This unit describes the skills and knowledge required to work positively with the carers and families of people using the service based on an understanding of their support needs. This unit applies to workers across a range of community services contexts. Disability Stream CHCDIS001 Contribute to ongoing skills development using a strengths-based approach This unit describes the skills and knowledge required to assist with supporting the ongoing skill development of a person with disability. It involves following and contributing to an established individual plan and using a positive, strengths-based approach. This unit applies to individuals who work with people with disability in a range of community services and health contexts. Work performed requires some discretion and judgement and may be carried out under regular direct or indirect supervision. CHCDIS002 Follow established person-centred behaviour supports This unit describes the skills and knowledge required to implement behaviour support strategies outlined in an individualised behaviour support plan for a person with disability. This unit applies to workers in varied disability services contexts. Work performed requires some discretion and judgement and may be carried out under regular direct or indirect supervision. CHCDIS003 Support community participation and social inclusion This unit describes the skills and knowledge required to assist with supporting people with disability in community participation and social inclusion using a person-centred approach. This involves enabling people to make choices to maximise their participation in various community settings, functions and activities to enhance psychosocial well-being and lifestyle in accordance with the person s needs and preferences. This unit applies to workers in varied disability services contexts. Work performed requires some discretion and judgement and may be carried out under regular direct or indirect supervision. CHCDIS007 Facilitate the empowerment of people with a disability This unit describes the skills and knowledge required to facilitate the empowerment of people with disability to deliver rights based services using a person-centred approach. It should be carried out in conjunction with individualised plans. This unit applies to workers in varied disability contexts. Page 11 of 21

12 CHCCCS011 Meet personal support needs This unit describes the skills and knowledge required to determine and respond to an individual s physical personal support needs and to support activities of daily living. This unit applies to workers who provide support to people according to an established individualised plan in any community services context. Work performed requires some discretion and judgement and may be carried out under regular direct or indirect supervision. HLTHPS006 Assist clients with medication This unit describes the skills and knowledge required to prepare for and provide medication assistance, and complete medication documentation. It also involves supporting a client to selfadminister medication. This unit applies to community services and health workers with authority in their state or territory to assist with the administration of medication. Home and Community Stream CHCAGE001 Facilitate the empowerment of older people This unit describes the skills and knowledge required to respond to the goals and aspirations of older people and provide support services in a manner that focuses on improving health outcomes and quality of life, using a person-centred approach. This unit applies to support workers in residential or community contexts. or CHCDIS007 Facilitate the empowerment of people with a disability This unit describes the skills and knowledge required to facilitate the empowerment of people with disability to deliver rights based services using a person-centred approach. It should be carried out in conjunction with individualised plans. This unit applies to workers in varied disability contexts. Plus CHCCCS011 Meet personal support needs This unit describes the skills and knowledge required to determine and respond to an individual s physical personal support needs and to support activities of daily living. This unit applies to workers who provide support to people according to an established individualised plan in any community services context. Work performed requires some discretion and judgement and may be carried out under regular direct or indirect supervision. Page 12 of 21

13 CHCCCS025 Support relationships with carers and families This unit describes the skills and knowledge required to work positively with the carers and families of people using the service based on an understanding of their support needs. This unit applies to workers across a range of community services contexts. CHCHCS001 Provide home and community support services This unit describes the skills and knowledge required to work in a home support environment and community settings with individuals, family members, staff, visitors, suppliers and others to meet established work requirements. This unit applies to workers in a community services context. Work performed requires some discretion and judgement and is carried out under regular direct or indirect supervision. CHCDIS003 Support community participation and social inclusion This unit describes the skills and knowledge required to assist with supporting people with disability in community participation and social inclusion using a person-centred approach. This involves enabling people to make choices to maximise their participation in various community settings, functions and activities to enhance psychosocial well-being and lifestyle in accordance with the person s needs and preferences. This unit applies to workers in varied disability services contexts. Work performed requires some discretion and judgement and may be carried out under regular direct or indirect supervision. HLTHPS006 Assist clients with medication This unit describes the skills and knowledge required to prepare for and provide medication assistance, and complete medication documentation. It also involves supporting a client to selfadminister medication. This unit applies to community services and health workers with authority in their state or territory to assist with the administration of medication. STAND ALONE ACCREDITED UNITS OF COMPETENCY Some students will simply want to undertake a specific unit of competency or a skill set from the qualification in order to fill a gap in their knowledge or maybe to allow them to progress in their current job. This is fine, as long as there are no prerequisite units of competency to the unit(s) that you wish to complete (if there are prerequisite units of competency, you will need to meet those requirements). Royal Rehab College does not have allocated NSW Smart and Skilled subsidised funding for single units or skills sets. Page 13 of 21

14 Also, sometimes students may like to obtain additional units of competency to the ones in their chosen stream of the qualification, if this is the case, please speak to your educator you will need to pay extra for these units of competency. The cost for single accredited units of competency is $ per unit, payable on enrolment. If you are an organisation looking to have a group of your employees trained in a certain area (either accredited or non-accredited training, please contact us to discuss your needs). You will have 6 months from your commencement date to complete the single unit of competency. If you are doing more than 1, or if you are doing a skill set, your educator will advise you of the date that you will need to complete by. Normally it would not be more than 12 months. Refunds will only be issued for units not commenced. FEES/CHARGES/REFUNDS The costs for your Certificate III in Individual Support course (online) are as follows: 2016 Full Fee for Service Students = $3250 Course cost includes: Learning materials and assessments for the 13 units of competency (includes the prerequisite units) Supported learning and mentoring from qualified disability, ageing support and home and community care professionals (your Educators) via phone and contact Web links to relevant materials and videos. This cost may be paid in one of 2 ways: Full cost upfront: You may choose to pay the full course cost on enrolment or Payment plan: You may pay the course cost over 15 equal monthly instalments. OTHER COSTS You are required to cover the costs of your work placement (travel, etc). For further additional costs please see our Schedule of Fees on our website for our full list of fees and charges. In addition to the course fees, you will have to: Have access to a computer with internet access Page 14 of 21

15 Access to a printer/multi page scanner. It is strongly preferred that you upload your assessments to the online platform, but if you are not able to, you can print and then post them to us A USB storage device (to ensure that you have a back up copy of your work, should your computer breakdown. REFUNDS If you choose to withdraw from the course, you may apply to Royal Rehab College for a refund for any units of competency that you have paid for in advance, but not commenced. Example 1 Full payment on enrolment: If you paid for the full course - $3250 on enrolment and withdrew after you had commenced and/or completed 6 units of competency the following amount would be refunded to you: The Certificate III in Individual Support contains 13 units of competency. Therefore, each unit of competency = $ Your refund for the 7 units of competency that you have not commenced would be $ Example 2 Payment using the Payment Plan If you had been paying by the payment plan each month for 6 months, but had only commenced 2 units of competency, the following amount would be refunded to you: The Certificate III in Individual Support contains 13 units of competency. Therefore, each unit of competency = $ each 2 units of competency = $ You would have already paid $ Your refund would be: $ However, you must withdraw from the course formally (by or by completing the withdrawal form on the website) and, Royal Rehab College must receive your application for refund form within 6 months of your withdrawal. WHAT HAPPENS NEXT? If you are interested applying for this course, please choose from the following options: 1. Complete the Application for Enrolment form on the Royal Rehab College website (choose the course you are interested) in and select the Enrol Now icon Page 15 of 21

16 2. Give us a call to ask any questions or request further information regarding the enrolment procedure 3. If you would like to speak to an Educator regarding the course content, job prospects or any part of the actual learning, please don t hesitate to contact us. If an Educator is not available when you ring, we can arrange to have someone contact you at a convenient time. Once enrolment is confirmed, you will be asked to pay either your full payment or your first payment plan instalment. CONTACTING THE COLLEGE Please contact the college if you have any questions about the content or assessment. Phone: college@royalrehab.com.au Address: The Royal Rehab College Part of Royal Rehab, The Rehabilitation & Disability Support Network 235 Morrison Road RYDE NSW 2112 Postal Address: The Royal Rehab College PO BOX 6 RYDE NSW 168 Page 16 of 21

17 APPENDIX A EXAMPLE OF ROYAL REHAB HEALTH ASSESSMENT FOR EMPLOYEES AND WORK EXPERIENCE STUDENTS The following form is an example only. The requirements may vary according to your placement factility. Page 17 of 21

18 Occupational Assessment, Screening and Vaccination against Specified Infectious Diseases PROCEDURES EMPLOYEE HEALTH ASSESSMENT Personal Details Gender: Female / Male (Please circle) Full Name: Date of Birth: / / Mobile: Address: Position Title: Department: Category A Protection against the specified infectious diseases is required Direct physical contact with: patients/clients deceased persons, body parts blood, body substances, infectious material or surfaces or equipment that might contain these (e.g. soiled linen, surgical equipment, syringes) Contact that would allow the acquisition or transmission of diseases that are spread by respiratory means. Includes persons: whose work requires frequent/prolonged face-to-face contact with patients or clients e.g. interviewing or counselling individual clients or small groups; performing reception duties in an emergency/outpatients department; whose normal work location is in a clinical area such as a ward, emergency department, outpatient clinic (including, for example, ward clerks and patient transport officers); or who frequently throughout their working week are required to attend clinical areas, e.g. food services staff who deliver meals. All persons working with the following high risk client groups or in the following high risk clinical areas are automatically considered to be Category A, regardless of duties. High risk client groups High risk clinical areas Children less than 2 years of age Ante-natal, peri-natal and post-natal areas including labour including neonates and wards and recovery rooms premature infants Neonatal Intensive Care Units and Special Care Units Pregnant women Paediatric wards Immunocompromised clients Transplant and oncology wards/ Intensive care units All health care students are Category A. Category B Does not require protection against the specified infectious diseases as level of risk is no greater than that of the general community Does not work with the high risk client groups or in the high risk clinical areas listed above. No direct physical contact with patients/clients, deceased persons, blood, body substances or infectious material or surfaces/equipment that might contain these. Normal work location is not in a clinical area, e.g. administrative staff not working in a ward environment, food services staff in kitchens. Only attends clinical areas infrequently and for short periods of time e.g. visits a ward occasionally on administrative duties; is a maintenance contractor undertaking work in a clinical area. Although such persons may come into incidental contact with patients (e.g. in elevators, cafeteria, etc) this would not normally constitute a greater level of risk than for the general community. Issue date: January 2011

19 Occupational Assessment, Screening and Vaccination against Specified Infectious Diseases PROCEDURES Information Sheet Checklist (Evidence required from Category A only) Evidence required to demonstrate protection against the specified infectious diseases 1. Acceptable evidence of protection against specified infectious diseases includes: a written record of vaccination signed by the medical practitioner, and/or serological confirmation of protection, and/or other evidence, as specified in the table below. NB: the health facility may require further evidence of protection, e.g. serology, if the vaccination record does not contain vaccine brand and batch or official certification from vaccination provider (eg clinic/practice stamp) 2. TST screening is required if the person was born in a country with a high incidence of TB, or has resided for a cumulative time of 3 months or longer in a country with a high incidence of TB, as listed at: 3. In certain specialised clinical settings, for example, in transplant, oncology or neonatal wards, the health facility may require serological evidence of protection (in addition to evidence of vaccination or other evidence) to ensure that the risk to vulnerable patients is minimised. Disease Evidence of vaccination Documented serology results Other acceptable evidence Diphtheria, tetanus, pertussis (whooping cough) One adult dose of diphtheria/ tetanus/ pertussis vaccine (dtpa). Not ADT. Serology will not be accepted Hepatitis B History of completed age or appropriate course of hepatitis B vaccine. Not accelerated course Measles, mumps, rubella (MMR) AN D Anti-HBs greater than equal to 10mIU/mL 2 doses of MMR at least one month apart vaccine Varicella (chickenpox) 2 doses of varicella vaccine at least a month apart (evidence of dose is sufficient if person was vaccinated before Tuberculosis (TB) See note 2 above for list of persons requiring TST screening Influenza Positive IgG for measles, mumps & rubella Positive IgG for varicella 14 years of age) varicella at least one month apart Not applicable O R O R Not applicable Not applicable Documented evidence of anti- HBc, indicating past hepatitis B infection Birth date before 1966 O mumps and rubella R History of chickenpox or physician- diagnosed shingles (serotest if uncertain) Tuberculin Skin Test (TST) Note: interferon-gamma release immunoassay (IGRA) is not generally accepted. In the event that an IGRA has been performed, screening by TST will be required if the IGRA result Persons with positive TST/IGRA must be fully assessed by a TB service within 3 months of commencement of clinical duties or clinical placement and must be asymptomatic when commencing clinical duties or clinical placement. Annual influenza vaccination is not a requirement, but is strongly recommended O R O R Issue date: January 2011

20 Tuberculosis (TB) assessment tool (Category A & B) - A New Recruit/Student will require TST screening if he/she was born in a country with a high incidence of TB, or has resided for a cumulative time of 3 months or longer in a country with a high incidence of TB, as listed at: - The Health Service will assess this form and decide whether clinical review/testing for TB is required. Indicate if you would prefer to provide this information in private consultation with a clinician. - New recruits will not be permitted to commence duties if they have not submitted this Form and Form 1: New Recruit Undertaking/Declaration to the employing health facility. Failure to complete outstanding TB requirements within the appropriate timeframe(s) may affect the new recruit s employment status - Students will not be permitted to attend clinical placements if they have not submitted this Form and the Form 3: Student Undertaking/Declaration to their educational institution s clinical placement coordinator as soon as possible after enrolment. Failure to complete outstanding TB requirements within the appropriate timeframe(s) will result in suspension from further clinical placements. The educational institution will forward the original or a copy of these forms to the health service for assessment. Clinical History Cough for longer than 2 weeks Yes No Please provide information below if you have any of the following symptoms: Haemoptysis (coughing blood) Yes No Fevers / Chills / Temperatures Night Sweats Fatigue / Weakness Anorexia (loss of appetite) Unexplained Weight Loss Yes No Yes No Yes No Yes No Yes No Assessment of risk of TB infection Were you born outside Australia? If yes, where were you born? Yes No.. Have you lived or travelled overseas? Country... Yes No Amount of time lived/ travelled in country Have you ever had: Contact with a person known to have TB? If yes, provide details below Yes No Have you ever had: TB Screening If yes, provide details below and attach documentation Yes No If you answered YES to any of the questions above, please provide details (attach extra pages if required). General Health Do you suffer from any known allergies, skin rashes or latex sensitivity? YES / NO List allergens:

21 Occupational Assessment, Screening and Vaccination against Specified Infectious Diseases PROCEDURES Employee Declaration (Category A & B) All new recruits must complete each part of this Employee Health Assessment / Declaration Form and the Tuberculosis (TB) Screening Assessment Tool and return these forms to the employing health facility as soon as possible. The health service will assess these forms along with evidence of protection against the infectious diseases specified in this policy directive. New employees/students will not be permitted to commence duties if they have not submitted a Employee Health Assessment / Declaration Form and the Tuberculosis Assessment Tool. Part 1 Part 2 Part 3 Part 4 I have read and understand the requirements of the NSW Health Occupational Assessment, Screening and Vaccination against Specified Infectious Diseases Policy Directive. I undertake to participate in the assessment, screening and vaccination process and I am not aware of any personal circumstances that would prevent me from completing these requirements OR I undertake to participate in the assessment, screening and vaccination process, however I am aware of medical contraindications that may prevent me from fully completing these requirements and am able to provide documentation of these medical contraindications. I request consideration of my circumstances. I have evidence of protection for: pertussis diphtheria tetanus varicella measles mumps rubella I have evidence of protection for hepatitis B OR I have received at least the first dose of hepatitis B vaccine (documentation provided) and undertake to complete the hepatitis B vaccine course (as recommended in the Australian Immunisation Handbook, current edition) and provide a post-vaccination serology result within six months of appointment/commencement of duties. I declare that the information I have provided is correct Name Signature Date Issue date: January 2011