General Request for Staff Form (QLD)
Updated 01.07.2024
Request date/time - no need to fill out this section it's automatic
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Minutes
AM
PM
AM/PM Option
Referring Agency
*
Office/Branch Name and Address
Contact Person Name
*
Contact Person Email Address
*
Contact Person Number
*
Child Safety Service Centre Manager Name
Child Safety Service Centre Contact Number
Contact Name for Accounts and Invoicing
*
Contact Number for Accounts and Invoicing
*
Is a purchase order required for payment of invoice? If so please add to the box provided
*
Yes
No
Other
Do you require a quote for this support request?
*
Yes
No
Requirements of Worker
Emerging Youth Worker (No Experience)
Category 1 (Entry level Experience)
Category 2 (Experienced)
Category 3 (Highly Experienced)
Category 4 (Professional Experience)
Is COVID 19 Vaccination required for the staff providing support?
*
Yes
No
Is your organisation a Licensed Care Service and does the worker require an LCS clearance with your organisation? NOTE: An LCS clearance is only available if the requesting organisation is a Licensed Care Service. Further information can be obtained here: https://www.cyjma.qld.gov.au/resources/dcsyw/about-us/partners/licensing/faq-organisation-apply-care-service.pdf
*
Yes
No
Date and Time of Shift
*
Job Brief
*
Does the assigned ProCare Australia worker require an NDIS Check Clearance to complete the shift requested?
*
Yes
No
Please upload any safety plans, PBS plans, risk assessments or any additional information which will assist in suitable matching of our staff to your request.
Browse Files
Upload relevant plans/information
Cancel
of
Approved Attendee/s (if required)
*
Name One
Name Two
Name Three
Name Four
Attendee/s Name
Relationship to Young Person
Are Case Notes required to be completed?
*
Not Required
15 Minutes
30 Minutes
Case Notes
Children/Young Person Information
*
Child Safety Seat
*
Forward Facing Infant
Rear Facing Infant
Booster Seat
No Booster seat
Are there know behaviours displayed by the Young Person when sitting in Child Safety Seats?
*
Yes
No
Please provide details of known behaviours:
*
eg: removing arms from restraint straps, removing seatbelt, opening doors, seat kicking, spitting on staff
Known Safety Concerns or Diagnosis
*
Please include all known challenging behaviours and an overview of any significant events that has the potential to influence the behaviours of the Young Person.
I acknowledge the information provided above is factual, and comprehensive at the time of submission of this form. I further acknowledge if additional information about safety concerns/diagnosis changes, I will update ProCare Australia with time of the essence?
*
Yes
No
Primary Carer Name
*
Primary Carer Address
*
Primary Carer Contact Number
*
Pre-Approved Allowances (if required)
*
Authorisation of shift Approval (If you require time sheets to be signed off after the shift please provide details below)
*
Name
Email
Position
Contact Number
Approver
Submit
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