RLSE Workplace Assessment Application

REAL LIFE SOCIAL ENTERPRISES - PARTICIPANT APPLICATION FORM

THE REAL LIFE HUB

MAIN SITE: 9 Old Springhill Rd, Coniston

EMPLOYMENT SUPPORTS - APPLICATION FORM

PARTICIPANT INFORMATION

Participant's First Name *

Participant's Last Name *

NDIS Number *

Contact Email *Please include the support coordinator's email if the participant does not have a personal email

i don't know the date of birth

Date of Birth *

Please estimate age or provide an age range *

Address

Contact Number

Does the participant receive DSP?

YesNoUnknown

Plan Manager Name & Information *

Plan Start Date *

Plan End Date *

Available days & times

Support Coordinator

NameEnter 'self managed' if the participant does not have a support coordinator

Phone

RLA Support Facilitator

Name

Phone

Applicant Questions

Do you hold a valid driver's licence?

YesNo

What are your main mode(s) of transport?

Car (I drive myself)Car (Someone else drives me)Public TransportWalk/Ride

What is the maximum number of hours of work you can do per day?

Do you have experience in the position of interest? If NO, see next question...

Have you held any positions in the past? If so, what was that role?

Do you have any special skills you think would be of value to this position?

What tasks would you like to do in this position?

Are you able to work comfortably in a team?

Can you easily follow instructions?

Do you have any physical disabilities that require workplace adjustments?

Do you require any specific assistance to carry out this role?

Do you have a resume or any relevant documents?

Browse

please attach

What are your likes?

What are your dislikes?

What is your primary and (if any) secondary disability?

Additional Comments

How did you hear about us?

Is the participant filling out this form? *

YesNo

Date

Name of Participant

Signature of Participant *

Draw signature|Type signatureClear

Name of person filling out form

Signature on behalf of participant *

Draw signature|Type signatureClear

Relationship to Participant

To be filled out by support coordinator

If you are not the support coordinator of the participant, please select "Save and Complete Later" at the bottom of the page. You will have the option to email a link to this form directly to the Support Coordinator's email if it is available.

Alternatively you can save the link and send via another method.

Does this participant have correct and sufficient funding to cover employment supports? *

What is the maximum number of hours for employment supports per week? *

NOTE re Ratio: Claim for the initial 20 hours Workplace Assessment is based on a 1:1 ratio

Save and Complete Later