Secondary Employment and Extra-Official Activities - Sydney South ...

Attachment 1:
Secondary Employment – Application Form
[to obtain approval to undertake secondary employment
(for all staff excluding staff specialists)]
APPLICANT’S DETAILS (in relation to their employment in SSWAHS)
Surname: ____________________________________ Name:____________________________________
Facility Name: __________________________________________________________________________
Department:____________________________________________________________________________
Employee Number: _______________________Classification:___________________________________
Position/Title: ___________________________________________________________________________
Department/Ward/Unit: _____________________________________Hours worked:___________________
Brief Description of Role / Responsibilities and shifts worked in SSWAHS:
_______________________________________________________________________________________
_______________________________________________________________________________________
APPLICANT’S SECONDARY EMPLOYMENT DETAILS
Name of Secondary Employer: ______________________________________________________________
Hours / Days to be worked in secondary employment:
Hours / week: _______ Days to be Worked: ____________________________________________
Brief Description of Secondary Employment:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Brief explanation as to why approval is being sought to undertake secondary employment (optional)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
DECLARATION STATEMENT:
“I, _______________________acknowledge that I understand that any second job or business I undertake
will be done in my own time, will not adversely affect my SSWAHS work, will not lead to conflict of interest,
will not involve SSWAHS resources, and will not involve the use of SSWAHS information”.
Signed: ____________________________________________ Date: ______________________________