8.2 BG NSW EMP DEC

APPENDIX E - Employment Declaration From
Employment Declaration

To be completed by the locum medical officer, copy retained by the Medical Locum Agency, original sent to Health District
Locum First Name*
Locum Middle Name
Locum Surname*
Locum Full Name*
Locum Contact No.*
Agency Name*
Date

DayMonthYear
Date
Type of employment
Details of other employers (attach a list of there is greater than two)
How Many Employers Details to Share?*

123 or more
Employer 1*
Name of Business
Employer Contact*
Full Name
Employer No.*
Contact No.
Details of Work Undertaken*
(including traveled time)
Average Weekly Hours*
Employer 2*
Name of Business
Employer 2 Contact*
Full Name
Employer 2 No.*
Contact No.
Details of work undertaken 2*
(including travel time)
Average Weekly Hours 2*
Average weekly average hours
Attach List of Additional Employers*

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I declare that:
- I have disclosed all other employers, internal or external to the potential engagement, including any other agencies and Health Districts;
- If I am currently working in a full time capacity within the NSW public health system, I have been given approval from my employer to engage in additional work through the locum agency;
- My other employment arrangements do not create any potential conflict of interest; occupational health and safety risks, or risk to quality patient service delivery during placement in a NSW Public Hospital.
I agree to inform my agency of any additional employers.
Locum Signature

Clear
Date

DayMonthYear
Date
Signature Attachment

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Submit this completed form to the Health Districtfor the placement of Locum Medical Officer
Should be Empty:

APPENDIX E - Employment Declaration From

Employment Declaration