Adjunct, Clinical and Associate Titles and
Visiting Fellows & Visiting Scholars
Checklist
The purpose of this checklist is to inform the application for a Clinical or Adjunct Title, Associate, or Visiting Fellow or
Visiting Scholar position with the University of Tasmania.
The relevant Organisational Unit head (or delegate) and the Nominee, are required to complete this form as a part of
the nomination process.
PART A
1. CONTACT DETAILS (to be completed by the Title holder, Associate, Visiting Fellow/Scholar at the time of
nomination)
Name
Address
Telephone No.
Mobile No.
Emergency Contact
Telephone No.
2. INFORMATION (for the nominee)
a) Work Health and Safety
In accordance with the Work Health and Safety Act 2012, a person undertaking a role with the University is to
comply with Section 28 of the Act and while at work must:
a) take reasonable care for his or her own health and safety; and
b) take reasonable care that his or her acts or omissions do not adversely affect the health and safety of
other persons; and
c) comply, so far as the worker is reasonably able, with any reasonable instruction that is given by the
University to allow the University to comply with this Act; and
d) cooperate with any reasonable policy or procedure of the University relating to health or safety at the
workplace that has been notified to workers.
b) Accidents and Injuries
If a person occupying a position is injured, or has an accident during the carrying out of their duties, they must
report it immediately to their Organisational Unit head or delegate.
All injuries/accidents will be formally recorded by the Organisational Unit head or delegate on-line, or on an
appropriate University of Tasmania Accident/Incident Report form.
c) Insurance
As the position holder is not an employee of the University of Tasmania they are not covered by Workers’
Compensation insurance.
However, they are covered under the University’s Personal Accident Insurance Policy for injuries sustained whilst
engaged in authorised activities (Noting an age limit of 80 years and general policy exclusions apply).
Refer to the University of Tasmania Insurance Guidelines for further details of insurance information).
d) General Conditions relating to positions
As the holder of an affiliate position with the University, a person:
 will not receive any remuneration for affiliate work;
 must not sub-contract work to any other person;
 must obey all reasonable requests made by the Organisational Unit head or Delegate and if a dispute
arises, should discuss the issue with the Organisational Unit head or Delegate;
 must comply with all security and office regulations in place at the University;
 shall not represent themselves as employees of the University of Tasmania.
The University of Tasmania may terminate affiliate appointments at its sole discretion.
e) Medical Disclosure
The University is to be advised of:
 any pre-existing medical condition or injury that would preclude the person from carrying out all of the duties
of the position;
 any medication that could affect the person’s health and safety, or the undertaking of their duties.
Please note that completion of Medical Disclosure and Authorisation Forms will be required where participating
in: laboratory, workshop, or studio work; field activities; work integrated learning activities; or undertaking required
driving.
1 Checklist (February 2015)
Adjunct, Clinical and Associate Titles and
Visiting Fellows & Visiting Scholars Checklist
3. INFORMATION RELATING TO THE POSITION (to be completed by the head of the Organisational Unit or
delegate at the time of nomination)
Organisational
Unit
Position Title
Organisational
Unit Head
Period of
Appointment
Location of
Position
Description of
Duties
Potential areas
of activity
From
Research projects
Collaborative research
Delivery of research papers
Publications
Postgraduate thesis supervision /mentoring
Postgraduate coursework lecturing
Undergraduate coursework lecturing
To
Practicum and work integrated learning
placement supervision
Public lectures
Workshops with staff, students and/or community
Short course and summer school teaching.
Other activities:
If the person is participating in field activities, laboratory, workshop, studio or other projects with an initial
assessed risk greater than 'Low' the head of the Organisational Unit is to approve a complete risk assessment in
accordance with the University’s Risk Management Policy and Matrix and include appropriate risk controls to
eliminate or minimise the risk so far as is reasonably practicable.
Risk Assessment attached?
YES
NO
4. PRE-APPOINTMENT CHECKLIST (to be completed by the head of the Organisational Unit or delegate)
a) Medical Disclosure
YES
NO
N/A
YES
NO
N/A
Does the person have a pre-existing medical condition or injury that would preclude
him/her from carrying out some or all of the duties of the position?
If YES, please provide details of the condition
……………………………………………………………………………………………..…..……
Is the person on any medication that could affect their health and safety, or the
operation of the work or project?
If YES, please provide details of the condition
……………………………………………………………………………………………..…..……
Note: the Supervisor is to be advised of this medication/condition before the person is
allowed to undertake the work or project.
 Field activities - has a Medical Disclosure and Authorisation Form been
completed?
 Laboratory, workshop, or studio work - has a Medical Disclosure and
Authorisation Form been completed?
 Driving - for an affiliate required to drive to and from a project, has a Driver Medical
Disclosure Form been completed?
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Adjunct, Clinical and Associate Titles and
Visiting Fellows & Visiting Scholars Checklist
Where a medical disclosure identifies a risk to the person, the University or other
persons, are reasonably practicable controls available to the University to manage these
risks to an acceptable level? (Seek WHS Advisor support if required)
Is specialist medical or insurance advice required?
Comment:
……………………………………………………………………………………………..…..……
b) Vulnerable People (please seek WHS Advisor support on this section if you are unsure)
Will the person come into contact with, or be required to work with children, the elderly
or other vulnerable people?
If ‘YES’ Is this addressed through professional registration?
If ‘YES’ and there is no professional registration, is a Police Check required?
Is a Working with Children Conduct Agreement required?
5. DECLARATION
I acknowledge that I have read and understand this document in relation to work in authorised activities on behalf
of the University of Tasmania. I undertake to advise the Organisational Unit head should circumstances change
during my appointment that would alter the responses provided above.
I have completed the sections of the document relevant to me and I declare that to the best of my knowledge the
information given by me is complete and true.
Name: ..………………………………………
(Position holder)
Signature: …………………………………….
Date:……………………………
Name …………………………………………
Date:…………………………..
(Organisational Unit head)
Signature: …………………………………..
Date:…………………………..
OFFICE USE ONLY
Work Health and Safety
Name
Signature
Date
Name
Signature
Date
Human Resources
3 Checklist (February 2015)
Adjunct, Clinical and Associate Titles and
Visiting Fellows & Visiting Scholars Checklist
PART B
1. INDUCTION
To be completed on commencement by the head of the Organisational Unit or delegate, together with the Position
Holder.
a) Work Health & Safety
Has the person been advised that he/she is a worker for the purposes of the Work Health and Safety Act
2012?
YES
NO
b) Induction
Which University induction and training (MyLO) needs to be undertaken before the person can undertake the
duties of the position? (Please select at least one)
Manager/Supervisor ..………………………………………………………………………………..…..…..
Affiliate ……….…………………………………………………………………………………..…..…..
Other .….……………………………………………………………………………………………..…..…….
c) Facilities and Equipment to be used by the person (e.g. laboratories, vessels, boats, computers, workshop
equipment, field equipment etc.)
……………………………………………………………………………………………..…..……………………..
Head of Organisational Unit or delegate to verify evidence of experience, if appropriate
……………………………………………………………………………………………..…..……………………..
What University specific induction and training needs to be undertaken before the person can use, operate
equipment, or undertake the duties of the position?
School/Section .………………………………………………………………………………………..…..…….
Laboratory/Workshop ………………………………………………………………………………..…..…….
FieldTeq™ ……………………………………………………………………………………………..…..…….
OnGuard™……………………………………………………………………………………………..…..…….
Other
……………………………………………………………………………………………..…..…….
Authorised Vehicle
YES
NO
YES
NO
2. Has the person been made aware of all Risk Assessments relating to their duties?
YES
NO
3. Has the person been made aware of safety issues relating to their duties?
YES
NO
4. Has safety equipment been issued to the person where required?
YES
NO
5. Does the person understand how to use and operate the safety equipment?
YES
NO
6. Does the person understand what action to take in the case of an emergency while
undertaking their duties?
YES
NO
Is the person required to drive between University workplaces in carrying out the duties
of the position?
If Yes, please complete the Authorisation to Drive a University Vehicle form.
d)
Safety Checklist
If the answer to any of the questions 1 to 6 is NO then a brief explanation is to be provided.
1. Has the person been made aware of the University of Tasmania’s Work Health and
Safety policies, minimum standards and procedures?
Refer to http://www.utas.edu.au/policy/by-category
4 Checklist (February 2015)
Checklist – Part B
2. DECLARATION
I acknowledge that I have read and understand this document in relation to work in authorised activities on behalf
of the University of Tasmania. I am required to abide by the Ordinances and Rules of the University of Tasmania.
That in the event of an injury which may entitle me to make a claim under the Personal Accident policy, I am
responsible for providing all relevant details/documentation relating to the injury so as to facilitate the claims
process.
I undertake to advise the Organisational Unit head should circumstances change during my appointment that
would alter the responses provided above.
I have completed all sections of the document with the head of the Organisational Unit and I declare that to the
best of my knowledge the information given in this form is complete and true.
Name: ..………………………………………
(Position holder)
Signature: …………………………………….
Date:……………………………
Name …………………………………………
Date:…………………………..
(Organisational Unit head or delegate)
Signature: …………………………………..
Date:…………………………..
OFFICE USE ONLY
Work Health and Safety
Name
Signature
Date
Name
Signature
Date
Human Resources
5 Checklist (February 2015)