General Request for Staff Form (QLD)

Request date/time - no need to fill out this section it's automatic

DateHourMinutesAM/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*

YesNoOther

Do you require a quote for this support request?*

YesNo

Requirements of Worker

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?*

YesNo

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*

YesNo

Date and Time of Shift*

Job Brief*

Does the assigned ProCare Australia worker require an NDIS Check Clearance to complete the shift requested?*

YesNo

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

Approved Attendee/s (if required) *

Rows	Name One	Name Two	Name Three	Name Four
Attendee/s Name
Relationship to Young Person

Are Case Notes required to be completed?*

Rows	Not Required	15 Minutes	30 Minutes
Case Notes

Children/Young Person Information*

Child Safety Seat*

Forward Facing InfantRear Facing InfantBooster SeatNo Booster seat

Are there know behaviours displayed by the Young Person when sitting in Child Safety Seats?*

YesNo

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 related to any of the attending Children? *

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.

Known Safety Concerns or Diagnosis related to any of the attending carers, parents, family members?*

Please include all known challenging behaviours and an overview of any significant events that has the potential to influence the behaviours of the attending adults.

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?*

YesNo

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) *

Rows	Name	Email	Position	Contact Number
Approver