EMPLOYEE INFORMATION FORM – NSW

Note: It is important our information is always up to date. Please provide to us so the

transition to Infinite Care can be as seamless as possible.

PERSONAL DETAILS
Surname: Khadka First Name: Sapna
Preferred
Date of Birth: 7/27/92 Gender: ☐ Male ☐
✔ Female
Name:
Street
Address: U 13/16 Bobart Street
Suburb: Parramatta State: NSW Post Code: 2150
Email
Address:
Khadkaswapnil13@gmail.com Mobile Number: 0410395953
☐ Yes (please specify)
✔
Do you speak any other languages other than English?
☐ No Nepali
Current position:

CURRENT SITE/S
☐ Casa Mia ☐ Chamberlain Gardens ☐ Southhaven

CURRENT EMPLOYMENT STATUS

☐ Full Time ☐ Part Time ✔ Casual
☐

ONGOING SHIFT AVAILABILITY

Identify below when you are available to work. Please ensure you are realistic below about your ability to work specified hours as
if you are not available as specified it may impact our ability to call you for future shifts. Every attempt will be made to develop
mutually agreed rosters.

Week 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning ✔ ✔ ✔

Afternoon ✔ ✔

Night ✔ ✔ ✔

Week 2 Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning ☐
✔ ☐
✔ ☐ ☐ ☐ ☐
✔ ☐
Afternoon ☐
✔ ☐ ☐ ☐ ☐ ☐
✔ ☐
Night ☐
✔ ☐ ☐ ☐ ☐ ☐
✔ ☐
✔

Would you like to work additional shifts?

ADDITIONAL INFORMATION

Do you have a Current Drivers Licence? ☐ Yes ☐

✔
No

If Yes, Licence Number:

Do you have:

A National Police Certificate ☐ Yes ☐

✔
No Date of Issue: _____________________

NDIS Workers Screening Clearance ☐ Yes ☐

✔
No Expiry: ___________________________
Copy of National Police Certificate or NDIS Workers
☐ Yes ☐
✔ No
Screening Clearance supplied?

If Yes, certificate / reference / Nation ID Number:

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Do you have any convictions? ☐ Yes ☐
✔
No

If Yes, please provide a summary:

(*) Please note: We are required to maintain a record of any Police Check and/or NDIS Workers Screening Clearance
(Clearance Check) including reference numbers and date of expiry to assist with ensuring that your Clearance Check does not
lapse and regulatory compliance is achieved. A copy of your Clearance Check is taken and filed within a secure HR filing
system. By providing us a copy and signing this form you agree to give Infinite Care permission to retain copies for these
purposes. Should your application be successful and you do not have a current Clearance Check, this will be required to be
provided to Infinite Care prior to commencement of your employment, and will be at the employee’s expense.
Do you have role-based Qualifications? ☐ Yes ☐
✔
No
Licence/APHRA
If yes, Qualification?
Number:

Date issued: Expiry date?

Copy of Qualification supplied ☐ Yes ☐ No

Do you have a current first aid certificate? ☐ Yes ☐

✔
No

Do you have a current CPR refresher? ☐ Yes ☐

✔
No

Have you had a flu vaccination? ☐ Yes ☐

✔ No Date of flu vaccination

Have you received both doses

☐
✔ Yes ☐ No Date of 1st COVID vaccination
of your COVID vaccination?

If no, please provide reason: ___________________ Date of 2nd COVID vaccination

Have you received the booster for your COVID

Date of 3rd COVID vaccination
vaccination?

What is your current pay point? Level Year

Language (if other than

Nepali Nationality: Nepalese
English):
Are you currently or have you previously been an
☐ Yes ☐
✔
No
employee of Infinite Care?
Do you know anyone who is a staff member or
resident within Infinite Care? (e.g: friend, relative, ☐
✔
Yes ☐ No
previous co-worker, etc)
If yes, please provide details including relationship to you:

ENTITLEMENT TO WORK IN AUSTRALIA

Proof of your entitlement to work in Australia must be provided prior to commencement of your employment. If your working rights
are under an alternative name, you may be requested to provide evidence such as a change of name and/or marriage certificate.

☐
✔
Passport ☐ Birth Certificate ☐ Citizenship Certificate ☐ Other

Copy of work entitlement document supplied? ☐ Yes ☐

✔
No

If you are supplying us with a valid visa with permission to work, this form provides us with permission to do a VEVO (Visa
Entitlement Verification Online) check. This process enables us to check the work entitlements of a visa holder online.

Visa Details: Post study work visa (bridging visa)

Date of Issue: Date of Expiry:

Work Conditions (if any): No

Copy of Visa supplied? ☐ Yes ☐
✔
No

Passport Details: 10110400 Country of Birth: Nepal

EMERGENCY CONTACT DETAILS
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Surname: Khadka First Name: Santosh
Street Address: U13/16 Bobart street
Suburb: Parramatta Post Code: 2150
Home Phone: Mobile Number: 0415520207
Relationship to you? Brother
SECONDARY EMPLOYMENT
Do you have secondary employment? (Including Volunteer work, Paid work with another organisation, work via a Recruitment
Agency, family business, etc.)

☐
✔
Yes, please complete the below for all secondary employments you may have; ☐ No

Name of
Romeo IGA Location Parramatta
Organisation/Business:

Position/Type of Work: cashier

Date Commenced: 1/7/18 End Date: 1/7/21 Time committed (estimate)
Name of
Fairfield Fruitland Location Fairfield
Organisation/Business:

Position/Type of Work: Cashier

Date Commenced: 1/11/19 End Date: Time committed (estimate)

Name of
Location
Organisation/Business:

Position/Type of Work:

Date Commenced: End Date: Time committed (estimate)

MEDICAL HISTORY

Have you been hospitalised in the last five (5) years? ☐ Yes ☐
✔
No

If Yes, provide details:

Have you attended a physiotherapist or chiropractor appointment in the past two (2) years? ☐ Yes ☐
✔
No

If Yes, provide details:

Do you have any medical condition that may require first aid at work (e.g. epilepsy)? ☐ Yes ☐
✔
No

If Yes, provide details:

Is there any physical, health or psychological condition that would preclude you from being able to
perform adequately the duties of any role specified in this application? ☐ Yes ☐
✔
No

If Yes, provide details:

Do you have any allergies? ☐ Yes ☐

✔
No

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If Yes, provide details:

EMPLOYEE DECLARATION
I confirm:
1. That the answers that I have provided in this enclosed form are to the best of my knowledge true and correct.
2. I will be bound by and at all times observe and respect such terms and conditions of my employment and such policies and
code of conduct as may from time to time be specified and documented by Infinite Care.
3. That I understand that any false information provided by me in this application may result in instant dismissal at any future
time.
4. I understand that my employment will be subject to satisfactory Police Check and any other employment checks and
screening that Infinite Care deem appropriate.
Full Name: SAPNA KHADKA
Signature: Date: 7/22/22

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