Transition To Work Direct Registration Form

Privacy and your personal information

Your personal information is protected by law, including the Privacy Act 1988 (Cth) and the Australian Privacy Principles. The personal information you provide (including sensitive information) is collected by your Transition to Work Provider on behalf of the Australian Department of Employment, Skills, Small and Family Business (the De partment) to:
work out whether you are eligible for Transition to Work Services
register you with a Transition to Work Provider
deliver services to you and help you improve your work readiness
help in evaluating and monitoring the services provided to you by the Department’s contracted p roviders
help to resolve complaints made by you or your Transition to Work Provider
so that you can be included in surveys conducted by the Department or on behalf of the Department. If you do not provide some or all of yo ur personal information, the Department cannot ensure that you are provided with the most suitable level of assistance. You can request assistance from your Transition to Work P rovider to complete this form if required. You may also have a nominee, includi ng a family member, advocate, social worker or counsellor, with you for support when filling out this form. Your personal information may be passed on to and betw een the Department’s contracted p roviders, and to agencies involved in the administration of employment services and income support payments and services, including the Department of Human Services, the Department of Education, the Department of Home Affairs , the Department of Social Services , the Aust ralian Taxation Office and the Department of the Prime Minister and

Cabinet and their respective contracted providers where those providers are delivering services to you. In addition, your personal information may also be shared with third parties, such as activity hosts and employers, in the delivery of services to you. Where appropriate to do so, this information may also be shared with and between these and other organisations (including contracted service providers) in the course of providing you with employment services and assistance and in evaluating and monitoring those services and assistance. Please note that your sensitive personal information may also be used by the Department or given to other parties where you have agreed, or where the Department is otherwise permitted, including where it is required or authorised by or under an Australian law, such as social security law, a court or tribunal order, or where a duty of care exists. The Department’s Privacy Policy contains more information about the way in which we will manage your personal information, including information about how you may access your personal information held by the Department and seek correction of such information. The Privacy Policy also contains information on how you can complain about a breach of the Australian Privacy Principles and how the Department will deal with such a complaint. A copy of the Department’s Privacy Policy can be found on the Privacy page of our website or by requesting a copy from the Department via email at privacy@employment.gov.au.

1. Participant identification details

Are you already registered with:

The Department of Human Services(Centrelink);
A Disability Employment Services provider;
An Australian Disability Enterprise;
A Community Development Programme provider;
A Harvest Labour Services provider;
A New Enterprise Incentive Scheme provider; or
A jobactive provider?

Yes No

If yes, please provide your Job Seeker Identification Number and/or your Department of Human Services Customer Reference Number (this information can be found on any letter to you from Department of Human Services or your Department of Human Services Health Care Card or Concession Card).

Job Seeker Identification Number

Department of Human Services Customer Reference Number

2. Your personal details

Title

Family name

First name(s)

Preferred name

Date of birth

Date

Gender

Male Female X (Indeterminate/Intersex/ Unspecified)

Country of birth

3. Do you identify as being of Aboriginal or Torres Strait Islander descent?

Yes No Prefer not to answer

Is English your First Language

Yes No

Do you require access to an interpreter

Yes No

If yes, what language?

4. Are you or have you been known by any other names?

Yes No

Other name(s)

5. Your Contact Details

Postal Address

Number and street / PO Box

Suburb or town

State or territory

Postcode

Residential address (if different from postal address)

Number and street

Suburb or town

State or territory

Postcode

Other Contact Details Best Contact Method

Home telephone number

Work telephone number

Mobile telephone number

Email address

example@example.com

Preferred Contact Method

Home Telephone Work Telephone Mobile Phone Email Address

6. Income Support

Do you receive a payment from the Department of Human Services?

Yes No

If yes, please provide the name of the payment.

(Your provider will confirm the type of payment with the Department of Human Services)

7. Personal Circumstances

a. are you an Australian Citizen or Permanent Resident

Yes No

if yes, go to 6d.

b. Are you a visa holder?

Yes No

If yes, please provide details about your visa and work rights.

c. Are you an overseas visitor to Australia, or here on a working holiday?

Yes No

d. Do you have a Year 12 Certificate or a Certificate III or higher qualification?

Yes No

If yes, please specify type of qualification.

e. If yes, did you get this Certificate more than six months ago?

Yes No

f. Are you currently working an average of 8 hours or more per week for a period of 13 weeks or more (104 hours)?

Yes No

g. If no, have you worked in paid employment in the last six months?

Yes No

h. . Are you currently enrolled in education?

Yes No

i. If no, have you been enrolled in education in the last six months?

Yes No

j. Have you attended education in the past 13 weeks?

Yes No

k. Do you have an approved exemption from legal requirements to attend school?

Yes No

You must provide the documentation specified in either Group A or Group B (detailed below)

Documents must be shown to your provider

You must provide one of the following:

Medicare card other (please specify)

Other

Drivers licence number

Current Australian passport number

Other form of photo identification from a government department or agency. Please specify type of identification.

Please specify type of identification.

Identification number

If you cannot provide information in either Group A or Group B, talk to your Transition to Work Provider about other documentation that is sufficient to prove your identity. For example, documentation that shows your name and address can be used to confirm your identity. This could include rates notices, mobile phone or other bills. Alternatively, other forms of documentation that contain your name, such as letters of reference, payslips from previous employment, library and other club memberships or education certificates may be used. Where you do not have sufficient documentation, the Department of Human Services may be able to assist.

You must provide two of the following:

financial institution (bank) documents including

ATM/credit cards showing name and signature bank statement showing name and address motor vehicle registration papers with current address

other documents—any of the following documents

birth certificate or birth certificate extract certificate of Australian citizenship motor vehicle registration papers with current Australian marriage certificate documents showing registration of a change of name divorce papers trade certificate insurance documents showing current address

Details of documentation shown to your Transition to Work Provider:

To be completed where the Participant is determined to be eligible for Transition to work services

By signing below, I confirm that:

I have read and understood the completed form, and the information included in the form is complete and true to the best of my knowledge.
I have read, understood and agree to the collection, use and disclosure of my personal information as outlined on the first page of this form and in the Department’s Privacy Policy (www.employment.gov.au/privacy)
I am not currently participating in any other Australian Government Employment programmes (such as jobactive, Disability Employment Services or the Community Development Programme)
I understand that if I am in receipt of the Disability Support Pension and volunteering for assistance, I may need an Employment Services Assessment to ensure I am referred to the most appropriate service and to determine suitable participation levels in that service. This will not review my eligibility for the Disability Support Pension.
I understand what Transition to Work Services I can receive, including what help I can access to improve my work readiness and examples of activities that I may take part in.
I understand that my personal information may be transferred between Transition to Work Providers for the purpose of delivering Transition to Work Services.
I understand my personal information may also be transferred between the Department, other contracted employment services providers and the Department of Human Services for the purposes of delivering employment services.
My Transition to Work Provider has explained the Service Guarantee and their Service Delivery Plan to me, if applicable.
I declare that, to the best of my knowledge, I am not prohibited by law from working in Australia.
I agree to participate in Transition to Work Services for up to 12 months unless I advise my Transition to Work Provider that I no longer wish to participate.

(Where applicable) Additional declaration by legal guardian or administrator of Participant:

I have been appointed the legal guardian or administrator of the Participant and as such, I am authorised to sign this declaration for, and on behalf of, the Participant (please tick box)

Yes

Signed: *

Note: Where the Participant has been appointed a guardian or administrator, the guardian or administrator should sign the declaration. Clear

Date:

Date

Printed name:

Direct Registration Form

Group A

Group B

Declaration by Participant: