Appendix 1 - Staff details

Staff details sheet completed for each location in the jurisdiction where the application is submitted and where workplace rehabilitation services may be delivered.

<table cellspacing="0" cellpadding="0" style="width:774pt; border-collapse:collapse"><tbody><tr style="height:13.5pt"><td style="width:116.6pt; vertical-align:bottom"><p><span style="font-weight:bold">ORGANISATION:</span></p></td><td colspan="7" style="width:358.85pt; border-bottom:1pt solid #000000; vertical-align:bottom"><p><span style="font-weight:bold"></span></p></td><td colspan="2" style="width:70.3pt; vertical-align:bottom"><p><span></span></p></td><td colspan="4" style="width:128.7pt; vertical-align:bottom"><p><span></span></p></td><td style="width:99.55pt; vertical-align:bottom"><p><span></span></p></td></tr><tr style="height:12.75pt"><td style="width:116.6pt; vertical-align:bottom"><p><span style="font-weight:bold">ADDRESS*:</span></p></td><td colspan="7" style="width:358.85pt; border-top:1pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:bottom"><p><span style="font-weight:bold"></span></p></td><td colspan="7" style="width:298.55pt; vertical-align:bottom"><p><span></span></p></td></tr><tr style="height:12.75pt"><td colspan="5" style="width:300pt; vertical-align:bottom"><p><span style="font-weight:bold">SITE OR PROVIDER APPROVAL NUMBER, IF APPLICABLE:</span></p></td><td colspan="2" style="width:132pt; border-bottom:0.75pt solid #000000; vertical-align:bottom"><p><span></span></p></td><td colspan="4" style="width:127.95pt; vertical-align:middle"><p style="text-align:right"><span style="font-weight:bold">DETAILS AS AT DATE:</span></p></td><td colspan="2" style="width:113.4pt; border-bottom:0.75pt solid #000000; vertical-align:bottom"><p><span></span></p></td><td colspan="2" style="width:100.65pt; vertical-align:bottom"><p><span></span></p></td></tr><tr style="height:12.75pt"><td style="width:116.6pt; vertical-align:bottom"><p style="font-size:11pt"><span></span></p></td><td colspan="2" style="width:103.8pt; vertical-align:bottom"><p><span></span></p></td><td colspan="2" style="width:79.6pt; vertical-align:bottom"><p><span></span></p></td><td colspan="2" style="width:132pt; border-top:0.75pt solid #000000; vertical-align:bottom"><p><span></span></p></td><td colspan="4" style="width:127.95pt; vertical-align:middle"><p style="text-align:right"><span></span></p></td><td colspan="4" style="width:214.05pt; vertical-align:bottom"><p><span></span></p></td></tr><tr style="height:66.3pt"><td colspan="2" style="width:127.5pt; border:1.5pt solid #000000; vertical-align:top; background-color:#ccccff"><p style="font-size:9pt"><span style="font-weight:bold">Name and position title</span></p></td><td colspan="2" style="width:127.5pt; border:1.5pt solid #000000; vertical-align:top; background-color:#ccccff"><p style="font-size:9pt"><span style="font-weight:bold">Qualifications</span></p><p style="font-size:9pt"><span style="font-weight:bold">include: qualification, institution, year of concurrence e.g. B.App Sci. OT Syd Uni – 1991</span></p></td><td colspan="2" style="width:127.5pt; border:1.5pt solid #000000; vertical-align:top; background-color:#ccccff"><p style="font-size:9pt"><span style="font-weight:bold">Years of Workplace Rehabilitation Experience</span></p></td><td colspan="3" style="width:127.5pt; border:1.5pt solid #000000; vertical-align:top; background-color:#ccccff"><p style="font-size:9pt"><span style="font-weight:bold">Basis of</span><br><span style="font-weight:bold">Employment</span><br><span style="font-weight:bold">(e.g. fee-for-service, part time or full-time)</span></p></td><td colspan="3" style="width:127.5pt; border:1.5pt solid #000000; vertical-align:top; background-color:#ccccff"><p style="font-size:9pt"><span style="font-weight:bold">Professional Membership or registration (Type and membership number)</span></p></td><td colspan="3" style="width:127.5pt; border:1.5pt solid #000000; vertical-align:top; background-color:#ccccff"><p style="font-size:9pt"><span style="font-weight:bold">Supervision arrangements for staff with less than 12 months experience.</span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:21.75pt"><td colspan="2" style="width:128.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="2" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p style="text-align:center"><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td><td colspan="3" style="width:128.62pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; vertical-align:top"><p><span></span></p></td></tr><tr style="height:0pt"><td style="width:116.6pt"></td><td style="width:12.4pt"></td><td style="width:91.4pt"></td><td style="width:37.6pt"></td><td style="width:42pt"></td><td style="width:87pt"></td><td style="width:45pt"></td><td style="width:43.45pt"></td><td style="width:40.55pt"></td><td style="width:29.75pt"></td><td style="width:14.2pt"></td><td style="width:85.05pt"></td><td style="width:28.35pt"></td><td style="width:1.1pt"></td><td style="width:99.55pt"></td></tr></tbody></table>