Appendix 2

Assessment Templates
Table of Contents
Assessment Task 1 Templates...........................................................................................1
Incident report...............................................................................................................1
Injury report ...................................................................................................................3
Risk assessment form ..................................................................................................8
Risk register ............................................................................................................... 10
Assessment Task 2 Templates........................................................................................ 11
Action/implementation plan ..................................................................................... 11
Budget ........................................................................................................................ 12
Communication plan (example) ................................................................................ 13
Assessment Task 3 Templates........................................................................................ 14
Roles and responsibilities ......................................................................................... 14
Budget ........................................................................................................................ 17
Assessment Task 4 Templates........................................................................................ 18
Professional development plan ................................................................................ 18
Third-party report ....................................................................................................... 23
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Assessment Task 1 Templates

Incident report
1. DETAILS OF PERSON MAKING REPORT

Name:
________________________________________________________________________

Position: __________________________________________ Job

Title: _____________________________________________
2. DETAILS OF INCIDENT

Date: ________________________________________ Time:

____________________________________________

Location:
________________________________________________________________________
Describe what happened and how:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

SUGGEST CORRECTIVE ACTIONS

_______________ _________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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________________________________________________________________________

________________________________________________________________________

3. DETAILS OF WITNESSES

Name: __________________________________ Job title:

________________________________________

Name: __________________________________ Job title:

________________________________________

Name: __________________________________ Job title:

________________________________________

Sign: ____________________________________ Date:

________________________________________

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Injury report

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Status:  Employee  Contractor  Other

Outcome:  Near miss  Injury
1. DETAILS OF INJURED PERSON

Name: _____________________________ Phone: (H) (W)

Address: ______________________________________ Sex:  M  F

_____________________________________________ Date of
birth: _________________________________________

Job
Title:
________________________________________________________________________

Start time:_________________________________________  am  pm
Work arrangement:  Casual  Full-time  Part-time  Other

2. DETAILS OF INCIDENT

Date: ___________________________________ Time:

_______________________________________

Location:
________________________________________________________________________

Describe what happened and

how:
________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
3. DETAILS OF WITNESSES

Name: ____________________________ Phone: (H) _____________ (W) ___________

Address:
________________________________________________________________________

________________________________________________________________________
4. DETAILS OF INJURY

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Nature of injury (e.g. burn, cut,

sprain)
________________________________________________________________________

Cause of injury (e.g. fall, grabbed by

person)
________________________________________________________________________

Location on body (e.g. back, left

forearm)
________________________________________________________________________

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5. TREATMENT ADMINISTERED

First aid given  Yes  No

First aider
name:
________________________________________________________________________

Treatment:
________________________________________________________________________

Referred
to:
________________________________________________________________________
SECTIONS 6–9 MUST BE COMPLETED BY EMPLOYER

6. DID THE INJURED PERSON STOP WORK?

 Yes  No If yes, state date: __________________

Time:

Outcome:

 Treated by doctor  Hospitalised  Workers compensation claim

 Returned to normal work  Alternative duties  Rehabilitation

7. INCIDENT INVESTIGATION (comments to include causal factors):

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
8. RISK ASSESSMENT

Likelihood of
recurrence:
________________________________________________________________________

Severity of
outcome:
________________________________________________________________________

Level of
risk:
________________________________________________________________________
9. ACTIONS TO PREVENT RECURRENCE

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Action By whom By when Date completed

10. ACTIONS COMPLETED

Signed
(Manager):
________________________________________________________________________

Title:
Date:

 Feedback to person involved

Date:

11. REVIEW COMMENTS

WHS committee / staff meeting: _____________________________________________

Reviewed by site Manager (signed): __________________________ Date:___________

Reviewed by Health and Safety Rep. (signed): _________________ Date: ___________

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Risk assessment form

Details

Name: _________________________________________________________________

Position: _______________________________________________________________
Risk details

Risk ID: _________________________________ Number allocated to this risk.

Raised by: _______________________________ Name of person who has raised the risk.

Date raised: ______________________________ Date of completion of this form.

Description of risk:
Briefly describe the identified risk and its possible impact.

Likelihood of risk: Impact of risk:

Describe and rank the likelihood of the risk Describe and rank the impact if the risk occurs
occurring (i.e. low, medium or high). (i.e. low, medium or high).

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Risk mitigation

Preventative actions recommended:

Briefly describe any action that should be taken to prevent the risk from occurring.

Contingency actions recommended:

Briefly describe any action that should be taken, should the risk occur, to minimise its impact.

Approval details

Supporting documentation:
Details of any supporting documentation used to substantiate this risk.

Signature: ________________________________________
Date: _____/_____/______

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Risk register
This template is used to record identified risks associated with your project, analyse the
impact and determine resultant action to be taken.

Risk response
Likelihood Impact
Risk (contingency Responsible
(H/M/L) (H/M/L)
strategies)

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Assessment Task 2 Templates

Action/implementation plan
Item Milestone date Responsibility

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Budget
Project Name:

Income Incl. GST Excl. GST

Total income

Expense Incl. GST Excl. GST

Subtotal

Contingency (+10%)

TOTAL

Signature: ________________________________________
Date: _____/_____/______

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Communication plan (example)

What Who Purpose When/frequency Type/methods
Initiation All stakeholders. Gather information FIRST Meeting.
meeting for initiation plan. Before project start
date.
Distribute All stakeholders. Distribute plan to Before kick-off Project snapshot
project alert stakeholders meeting. distributed via
initiation of project scope Before project start hard copy or
plan and to gain date. electronically.
support. May be posted on
project website.

Project All stakeholders. Communicate At or near project Meeting.

kick-off plans and start date.
stakeholder roles/
responsibilities.
Encourage
communication
among
stakeholders.

Status All stakeholders Update Regularly Distribute status

reports and project officer. stakeholders on scheduled. report electronically
progress of the Weekly is and post via
project. recommended for website.
small–medium
projects.
Team Entire project team. Review of detailed Regularly Meeting: detailed
meetings Individual meetings plans (tasks, scheduled. plan.
for sub-teams as assignments, and Weekly is
appropriate. action items). recommended for
entire team. Weekly
or bi-weekly for
sub-teams as
needed.
Sponsor Sponsor/s and Update sponsor/s Regularly Meeting.
meetings Project Manager. on status and scheduled.
discuss critical Recommended
issues. bi-weekly or
Seek approval for monthly and also
changes to project as needed when
plan. issues cannot be
resolved or
changes need to be
made to project
plan.

Media and Marketing team. Promote benefits of As determined by Internet, magazine,

community the project to marketing team. radio.
promotion community.

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Assessment Task 3 Templates

Appendix 10: Meeting agenda template

Meeting title:

Venue, time, date, duration:

Agenda

No. Time Item Responsible

1. Opening/Welcome Chairperson

2.

3.

4.

5.

6.

7.

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8. Adjournment/Next Meeting Chairperson

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Roles and responsibilities

Role Name/s Responsibilities Signature/s

(if required)

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Budget
Project Name:

Income Incl. GST Excl. GST

Total income

Expense Incl. GST Excl. GST

Subtotal

Contingency (+10%)

TOTAL

Signature: ________________________________________
Date: _____/_____/______

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Assessment Task 4 Templates

Professional development plan
Name

Date of development Date to be reviewed

 Discussed with mentor/colleague

 Discussed with manager
Name: Name:

Goals

Timeframe My personal goals are: My professional goals are:

These should relate to or support professional goals These should relate to objectives to maintain current
competence in the job role or future career paths.

Next 12 months
This will depend on type
of activity priority/
importance of
undertaking it

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Timeframe My personal goals are: My professional goals are:

These should relate to or support professional goals These should relate to objectives to maintain current
competence in the job role or future career paths.

Next 5 years
This will depend on type
of activity priority/
importance of
undertaking it

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Strengths and Weaknesses

Timeframe Personal Professional

Required
knowledge/skills
Consider:

 required
competencies
 job description
 service plans and
frameworks.

Strengths
Consider:

 your views
 recent
tests/appraisals
 other people’s views.

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Timeframe Personal Professional

Gaps/barriers/
obstacles and
solutions
 gaps in knowledge/
skills
 changes to systems/
services requiring
new skills
 what will help you to
progress in your role,
profession?

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Professional Development and Networking Activities

Development Details (provider, Objective of development/

Identified gap Timeframe Cost
activity location, etc.) networking activity

1.

2.

3.

4.

5.

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Third-party report

Name of observer: _______________________________________________________

Position: _______________________________________________________________

Contact details: _________________________________________________________

_______________________________________________________________________

_______________________________________________________________________
Skill Description of how candidate demonstrated
skill/knowledge. Provide example.

Demonstrates
interpersonal skills to
communicate and
inspire the trust and
confidence of others,
and ensure their
cooperation and support.

Demonstrates
networking skills to
ensure support from key
groups and individuals
for concepts/ideas/
products/services.

Applies business ethics.

Ensures performance is
continuously improved
through participation in
professional
development,
networking, etc.

Signature: ________________________________________
Date: _____/_____/______

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