FACULTY OF EDUCATION AND ARTS School of Education, QLD

2016 PEP UNIT BOOKLET

EDFX473 EDFX414

This booklet should be read in conjunction with the

2016 PROFESSIONAL EXPERIENCE PROGRAM (PEP) GENERAL INFORMATION HANDBOOK

PEP Co-ordination Michael Chambers Phone: 07 3623 7204 Email: michael.chambers@acu.edu.au PEP Administrative Officer

Ms Bernadette O’Malley Phone: 07 3623 7442 Fax: 07 3623 7247 Email FEA.PlacementsQLD@acu.edu.au

PROFESSIONAL EXPERIENCE PROGRAM CALENDAR 2016

Bachelor of Teaching/Bachelor of Arts Year Level

Semester 1 Semester 2

Fourth Year

EDFX473 Professional Experience Block Practicum: six weeks 9 May – 17 June

EDFX414 Extended Reflective Practice Block Practicum: six weeks 10 October – 18 November

It is the students’ responsibility to ensure they have a “Blue Card” and that it is valid. Students

without a valid Blue Card are prohibited from entering classrooms.

‘Supervised professional experience is at the heart of all our Initial Teacher Education courses and the Faculty will find appropriate placements to suit the needs of your course. Placements will usually be arranged for the scheduled placement period in the professional experience calendar, although this may not always be possible.’

EDFX473 PROFESSIONAL EXPERIENCE

During Professional Experience Secondary, students will be expected to undertake observations of classrooms, assist individual students with learning, assist School Mentors in team teaching and prepare and present whole class lessons. In the final week of this Professional Experience block, students should prepare and deliver a three lesson sequence in at least two curriculum areas. The type of activities expected to be undertaken by Pre-service Teachers is set out in the table below. The number of lessons per week are set out, however, it is to be expected that sometimes the exact number of lessons might not be reached during that week. It is expected, that over the duration of the placement that ideally students meet these requirements.

Week 1

Pre-service Teacher is expected to take responsibility, with the support of School Mentors, for the preparation and delivery of four lessons per day – ideally within two different curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Week 2

Pre-service Teacher is expected to take responsibility for the preparation and delivery of four lessons per day – ideally within two different curriculum areas. In addition, the student is responsible, with the assistance of School Mentors, for the preparation and delivery of a three lesson sequence within at least two curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Week 3

Pre-service Teacher is expected to take responsibility for the preparation and delivery of five to six lessons per day – ideally within two different curriculum areas. In addition, the student is responsible, with the assistance of School Mentors, for the preparation and delivery of a three lesson sequence within at least two curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Interim report due.

Week 4

Pre-service Teacher is expected to take responsibility for the preparation and delivery of approximately 80% of lessons per day – ideally within two different curriculum areas. In addition, the student is responsible, working independently but in consultation with the School Mentor, for the preparation and delivery of a three lesson sequence within at least two curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Week 5

Pre-service Teacher is expected to take responsibility for the preparation and delivery of approximately 80% of lessons per day – ideally within two different curriculum areas. In addition, the student is responsible, working independently but in consultation with the School Mentor, for the preparation and delivery of a two week sequence of lessons within at least two curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Week 6

Pre-service Teacher is expected to take responsibility for the preparation and delivery of approximately 80% of lessons per day – ideally within two different curriculum areas. In addition, the student is responsible, working independently but in consultation with the School Mentor, for the preparation and delivery of a two week sequence of lessons within at least two curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Final report due.

It is the responsibility of the Pre-Service Teacher to submit all paperwork within 10 business days of completing their practicum placement. If this deadline is not met a FAIL GRADE will be awarded for the unit and the student will need to repeat the placement in subsequent semesters. Guidelines for School Visits

The following are general guidelines for School Visitors Talk with all School Mentors about a Pre-service Teacher's progress and ACU’s reporting process; Week 1 & 2: During the first week of the block, contact the school to enquire about student(s) progress. If

there appear to be problems /difficulties, flag these with Professional Experience Coordinator immediately, in order to put in place contingency plans.

Week 3 & 4: Complete initial school visits;

Pre-service teachers provided with feedback on performance

Work with School Mentors to complete the Interim Professional Experience Report

"At Risk of Failing" Pre-service Teachers identified and made aware of this by the School Mentor as early as possible; Contact Course Coordinator by the end of this week.

"At Risk of Failing" Pre-service Teachers notified in writing

Professional Experience Visitor - suggests ways of improvement

Weeks 5: Continue visits as necessary. Week 6: Remind School Mentors of reporting process:

A separate report is required for each curriculum area

Reports are to be completed ad signed by School Mentors, then submitted to School Coordinator for signing in time for Pre-service Teacher to collect at end of week (Friday, Week 6). Pre-service Teachers must deliver their reports to the School of Education Office on the Monday after the block Professional Experience is completed.

ASSESSMENT OF PROFESSIONAL EXPERIENCE

Assessment for the professional Experience will be based on the following

Professional Experience Report

Folio of lesson plans

Completing a Guided Reflection The Professional Experience Report will be graded within the following dimensions:

The Professional Person

Teacher as Planner

Teacher in Action

Each of these dimensions will be judged within each curriculum area as:

Exceeded

Met

Emerging

Not Met The final grade for the report for each curriculum area is Satisfactory/Unsatisfactory. To achieve a Satisfactory the Pre-service Teacher must achieve at least an Emerging grade within each dimension.

The Folio of Lesson Plans must include evidence of preparation for all lessons presented. The Folio will be graded Satisfactory/Unsatisfactory.

A Professional Experience Log and Guided Reflection must be completed by each student. In this Log, the Pre-service Teacher must record their daily activity in the school including observations, teaching, lesson planning, co-curricular activity etc. The Log will be graded Satisfactory/Unsatisfactory. A completed Guided Reflection, will consist of a written reflection of approximately 300 words. The reflection will be graded Satisfactory/Unsatisfactory. Please use the pro forma provided.

It is the responsibility of the Pre-Service Teacher to submit all paperwork within 10 business days of completing their practicum placement. If this deadline is not met a FAIL GRADE will be awarded for the unit and the student will need to repeat the placement in subsequent semesters. Report Forms Report forms required for each practicum are available from the ACU Faculty of Education and Arts, School of Education (Qld) website at: www.acu.edu.au/PEPQLD

EDFX473 Professional Experience Program Interim Report

Pre-service Teacher Name:

School:

Associate Teacher:

Year:

This interim report should be completed by the Associate Teacher and discussed with the Pre-Service Teacher at the MIDWAY POINT of the Professional Experience.

Teacher as Professional Not Met ☐ Emerging ☐ Met ☐ Exceed ☐

Responsibility for Personal Development • Actively seeks opportunities for personal

development • Is open and responsive to the guidance of

mentors and supervisors • Behaves ethically and with regard to the

legal obligations of teachers • Adheres to appropriate dress standards • Meets personal work-related goals and

priorities • Works in partnership with teachers and other

professionals

• Communicates in an appropriate and professional manner

Comments:

Teacher as Planner Not Met ☐ Emerging ☐ Met ☐ Exceed ☐

Planning • Demonstrates a sound knowledge of content,

processes and skills of KLAs and links across KLAs

• Plans learning experiences effectively

Comments:

Teacher in Action Not Met ☐ Emerging ☐ Met ☐ Exceed ☐

• Projects and uses voice effectively • Written and verbal communication accurate,

clear and grammatically correct • Uses teaching time, materials, resources and

physical space safely and effectively • Monitors independent and group work

encouraging the participation of all students • Understands and applies techniques for

scaffolding and supporting student learning • Provides timely appropriate feedback to

students on their learning • Encourages students to ask question,

exchange idea and engage in higher order thinking

• Is beginning to identify and apply behaviour management strategies in a fair, sensitive and consistent manner

Comments:

Please place School Stamp here: This report has been endorsed by:

Australian Catholic University

Faculty of Education & Arts Qld

Number of PEP days completed: Choose an item. Days

Professional Experience Interim Result: At Risk ☐ Satisfactory

☐

Associate Teacher:

Date: Click here to enter a

date.

School Coordinator:

Date: Click here to enter a

date.

Pre-Service Teacher:

Date: Click here to enter a

date.

EDFX473 Professional Experience Program Final Report

Pre-service Teacher Name:

School:

Associate Teacher:

Year:

This final report should be completed by the Associate Teacher and discussed with the Pre-Service Teacher at the on COMPLETION of the Professional Experience.

Teacher as Professional QCT Professional standards 6, 8, 9 and 10 and including

Not Met ☐ Emerging ☐ Met ☐ Exceed ☐

Responsibility for Personal Development • Sets personal professional goals • Actively seeks opportunities for personal

development

• Is open and responsive to the guidance of mentors and supervisors

Comments:

Professional Attitudes and Practices • Appropriately performs all duties in a

manner consistent with school policies and procedures

• Behaves ethically and with regard to the legal obligations of teachers

• Adheres to appropriate dress standards

• Meets personal work-related goals and priorities

Comments:

Professional Relationships within the School Community

• Works in partnership with teachers and other professionals

• Communicates in an appropriate and professional manner

• Contributes to the co-curricular program of the school

Comments:

Teacher as Planner QCT Professional Standards 1-4 including

Not Met ☐ Emerging ☐ Met ☐ Exceed ☐

Demonstrates a sound knowledge of content, processes and skills of KLAs and links across KLAs

Designs effective learning experiences

Designs learning experiences that develop language, literacy and numeracy

Designs intellectually challenging learning experiences

Comments:

Please place School Stamp here: This report has been endorsed by:

Australian Catholic University

Faculty of Education & Arts Qld

Teacher in Action QCT Professional standards 1-4 and 7, 8 including

Not Met ☐ Emerging ☐ Met ☐ Exceed ☐

Communication • Projects and uses voice effectively • Written and verbal communication accurate,

clear and grammatically correct

• Communicates effectively and ethically with both professional and community members of school learning environments

Comments:

Instructional Skills • Uses teaching time, materials, resources

and physical space safely and effectively • Monitors independent and group work

encouraging the participation of all students • Understands and applies techniques for

scaffolding and supporting student learning • Provides timely appropriate feedback to

students on their learning

• Encourages students to ask question, exchange idea and engage in higher order thinking

Comments:

Managing Students and Learning Contexts • Establishes clear expectations for student

learning and behaviour • Provides explicit feedback for students on

appropriate behaviour

• Identifies and applies behaviour management strategies in a fair, sensitive and consistent manner

Comments:

Summary Comments:

Number of PEP days completed: Choose an item. Days

Professional Experience Final Result: Pass ☐ Fail ☐

Associate Teacher:

Date: Click here to enter a

date.

School Coordinator:

Date: Click here to enter a

date.

Pre-Service Teacher:

Date: Click here to enter a

date.

Guided Reflection Write a reflection on the topics below. These might be areas you observed during your practicum placement or they may be areas you tried new strategies or made modifications to your approach.

Behavioral Management Strategies (what did you observe, what did you try, what worked, what didn’t work)

Planning (how effective was your planning, what do you need to change, what worked, what didn’t work)

Discussions with Supervising teacher (what was discussed, what was learnt, what you would like to do differently next time, what worked, what didn’t work)

Observation & Teaching Log Item Date Year Time Lesson & lesson topic Teacher

e.g. 07.09.14 Yr 8 10:20-

11:00am

Geography

Ocean currents

Miss Grant

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

EDFX414 PROFESSIONAL EXPERIENCE During Professional Experience Secondary, students will be expected to undertake observations of classrooms, assist individual students with learning, assist School Mentors in team teaching and prepare and present whole class lessons. In the final week of this Professional Experience block, students should prepare and deliver a three lesson sequence in at least two curriculum areas. The type of activities expected to be undertaken by Pre-service Teachers is set out in the table below. The number of lessons per week are set out, however, it is to be expected that sometimes the exact number of lessons might not be reached during that week. It is expected, that over the duration of the placement that ideally students meet these requirements.

Week 1

Pre-service Teacher undertakes 2-3 days of observation. After that time the pre-service teacher is expected to take responsibility, with the support of School Mentors, for the preparation and delivery of 3 x 40 minute lessons per day (or equivalent) – ideally within two different curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Week 2

Pre-service Teacher is expected to take responsibility for the preparation and delivery of 3 x 40 minute lessons per day (or equivalent) – ideally within two different curriculum areas. In addition, the student is responsible, with the assistance of School Mentors, for the preparation and delivery of a three lesson sequence within at least two curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Week 3

Pre-service Teacher is expected to take responsibility for the preparation and delivery of 4-5 x 40 minute lessons per day – ideally within two different curriculum areas. In addition, the student is responsible, with the assistance of School Mentors, for the preparation and delivery of a three lesson sequence within at least two curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Interim report due.

Week 4

Pre-service Teacher is expected to take responsibility for the preparation and delivery of approximately 80% of lessons per day – ideally within two different curriculum areas. In addition, the student is responsible, working independently but in consultation with the School Mentor, for the preparation and delivery of a three lesson sequence within at least two curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Week 5

Pre-service Teacher is expected to take responsibility for the preparation and delivery of approximately 80% of lessons per day – ideally within two different curriculum areas. In addition, the student is responsible, working independently but in consultation with the School Mentor, for the preparation and delivery of a two week sequence of lessons within at least two curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Week 6

Pre-service Teacher is expected to take responsibility for the preparation and delivery of approximately 80% of lessons per day – ideally within two different curriculum areas. In addition, the student is responsible, working independently but in consultation with the School Mentor, for the preparation and delivery of a two week sequence of lessons within at least two curriculum areas. The remaining time in a day should include observations within at least two of their curriculum areas. Time should also be set aside for students to attend meetings as deemed appropriate by a Pre-service Teacher’s Mentors or the school professional experience coordinator and to complete a reflective diary.

Final report due.

It is the responsibility of the Pre-Service Teacher to submit all paperwork within 10 business days of completing their practicum placement. If this deadline is not met a FAIL GRADE will be awarded for the unit and the student will need to repeat the placement in subsequent semesters. Guidelines for School Visits

The following are general guidelines for School Visitors Talk with all School Mentors about a Pre-service Teacher's progress and ACU’s reporting process; Week 1 & 2: During the first week of the block, contact the school to enquire about student(s) progress. If

there appear to be problems /difficulties, flag these with Professional Experience Coordinator immediately, in order to put in place contingency plans.

Week 3 & 4: Complete initial school visits;

Pre-service teachers provided with feedback on performance

Work with School Mentors to complete the Interim Professional Experience Report

"At Risk of Failing" Pre-service Teachers identified and made aware of this by the School Mentor as early as possible; Contact Course Coordinator by the end of this week.

"At Risk of Failing" Pre-service Teachers notified in writing

Professional Experience Visitor - suggests ways of improvement

Weeks 5: Continue visits as necessary. Week 6: Remind School Mentors of reporting process:

A separate report is required for each curriculum area

Reports are to be completed ad signed by School Mentors, then submitted to School Coordinator for signing in time for Pre-service Teacher to collect at end of week (Friday, Week 6). Pre-service Teachers must deliver their reports to the School of Education Office on the Monday after the block Professional Experience is completed.

ASSESSMENT OF PROFESSIONAL EXPERIENCE

Assessment for the professional Experience will be based on the following

Professional Experience Report

Folio of lesson plans

Completing a Guided Reflection The Professional Experience Report will be graded within the following dimensions:

The Professional Person

Teacher as Planner

Teacher in Action

Each of these dimensions will be judged within each curriculum area as:

Exceeded

Met

Emerging

Not Met The final grade for the report for each curriculum area is Satisfactory/Unsatisfactory. To achieve a Satisfactory the Pre-service Teacher must achieve at least an Emerging grade within each dimension. The Folio of Lesson Plans must include evidence of preparation for all lessons presented. The Folio will be graded Satisfactory/Unsatisfactory. A Professional Experience Log and Guided Reflection must be completed by each student. In this Log,

the Pre-service Teacher must record their daily activity in the school including observations, teaching, lesson planning, co-curricular activity etc. The Log will be graded Satisfactory/Unsatisfactory. A completed Guided Reflection, will consist of a written reflection of approximately 300 words. The reflection will be graded Satisfactory/Unsatisfactory. Please use the pro forma provided.

It is the responsibility of the Pre-Service Teacher to submit all paperwork within 10 business days of completing their practicum placement. If this deadline is not met a FAIL GRADE will be awarded for the unit and the student will need to repeat the placement in subsequent semesters.

EDFX414 – interim and final reports

QLD Final Year Professional Experience Report must to be used for Interim and Final reports. This Report can be found online at www.acu.edu.au/PEPQLD (See the excerpt below for clarification on names)

Section 8: Moderation

Please identify who has moderated the assessment of the preservice teacher.

Moderation may be completed through classroom visit/s or as a panel discussing the evidence and awareness

demonstrated by the preservice teacher.

Site coordinator’s name Signature

Date

/

/

Higher education institution

(HEI) representative’s name

Signature Date

/

/

Name of HEI representative who

conducted school visits

Dates of school visit/s

/

/

Signature Date

/

/

Other moderator name and

position if applicable

Signature Date

/

/

Section 9: Signatures

Each of the signatories must retain a copy of this report for their records.

The preservice teacher’s signature indicates they have sighted this completed report.

Preservice teacher’s name Signature

Date

/

/

Supervising teacher’s name Signature

Date

/

/

Other supervising teacher’s

name

Signature

Date

/

/

© State of Queensland (Department of Education and Training) [2015]

The site Co-ordinator is the School Co-ordinator

The HEI Representative is Visitor from ACU

The Higher Education institution Representative is the ACU PEP Co-ordinator

Guided Reflection Write a reflection on the topics below. These might be areas you observed during your practicum placement or they may be areas you tried new strategies or made modifications to your approach.

Behavioral Management Strategies (what did you observe, what did you try, what worked, what didn’t work)

Planning (how effective was your planning, what do you need to change, what worked, what didn’t work)

Discussions with Supervising teacher (what was discussed, what was learnt, what you would like to do differently next time, what worked, what didn’t work)

Observation & Teaching Log Item Date Year Time Lesson & lesson topic Teacher

e.g. 07.09.14 Yr 8 10:20-

11:00am

Geography

Ocean currents

Miss Grant

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

FIELD EXPERIENCE EMERGENCY CONTACT FORM

Pre-Service Teacher’s Name: ................................................................................................... Pre-Service Teachers are requested to complete this form, place it in a sealed envelope marked with (Insert Name), ACU Pre-Service Teacher, Emergency Contact Details, ‘Confidential’ then, on the first day of the professional experience, leave it with the School/Centre administration for the duration of the practicum. Pre-Service Teachers can collect the form on the last day of the practicum.

In case of an emergency, the School will contact the designated person(s).

Contact Person(s):

Name: Relationship: E.g. Mother

Phone Number(s):

1

2

3

In case of an emergency, I, ……………………………………..........give the School where I am placed for professional experience, permission to seek medical assistance or call an ambulance if deemed necessary. Pre-Service Teacher’s Signature: …………………………........ Date: ………………............ Medicare Number: ………………………………………………………...……................................ Ambulance Subscription: …………………………………………………….………...…................ Name of Doctor: ………………………………………………….…………….................................. Doctor Phone No: …………………………………………….…………………................................

Please list any allergies or important medical information (e.g. asthma, diabetes) ……………………………………………………………………………………..……………................ ………………………………………………………………………………………………….................. ………..………………………………………………………………………………………….………….. ……………………………………………………………………………………………………………..... ……………………………………………………………………………………………………………….

Privacy Statement Australian Catholic University is committed to ensuring the privacy of all information it collects. Personal information supplied in this application form will only be used for administrative and educational purposes of the institution. Personal informat ion collected by the University will only be disclosed to third parties with the written consent of the person concerned, unless

otherwise prescribed by law. For further information, please see the University’s Statement on Privacy, which is available at http://www.acu.edu.au/451562

INDUSTRY PLACEMENT INSURANCE

29 October 2015

To Whom It May Concern:

‘Organisation’ those who provide unpaid industry experience or volunteer community engagement for students of Australian Catholic university

The purpose of this letter is to advise organisations that provide unpaid industry experience or a volunteer

community engagement experience to students of Australian Catholic University in relation to course requirements, that the following insurance covers have been arranged by the University:

1. General & Product Liability

Policy Number: ACU 16 GPL Period of Cover 01/11/2015 to 31/10/2016

2. Professional Liability Policy Number: ACU 16 PL Period of Cover 01/11/2015 to 31/10/2016

3. Students Work Experience Personal Accident Policy Number: 02.PAE. 110727 Period of Cover 01/11/2015 to 31/10/2016

I can be contacted on (02) 9739 2945, if you require further information

Rajan Wijey Insurance Manager

School of Education (Qld)

PROFESSIONAL EXPERIENCE SECONDARY PAYMENT CLAIM FORM

RECIPIENT TAX INVOICE

ABN: 15 050 192 660

School Coordinator: _______________________________

School: _______________________________________ Address: __________________________

Postcode: __________________ Phone: __________________________________

School Type: Catholic School (Systemic Non Systemic CB Systemic )

State School Lutheran School Anglican School Other School

(Teachers from any school other than Catholic, are required to complete a Bank/Tax Details Form and submit attached to this Claim Form.)

Associate Teacher ACU Student Curriculum Area

Office use only

Approved by PEP officer

e.g. A Teacher A Student English – 50%

e.g. B Teacher B Student History – 50%

CERTIFICATION BY COORDINATOR I hereby certify that appropriate supervision of the above named students were carried out and that the above details are correct. SIGNATURE OF COORDINATOR: _______________________________________ DATE: _______________

Please return forms to Professional Experience Program Officer, Australian Catholic University, PO Box 456, Virginia Qld 4014

Australian Catholic University – McAuley at Banyo PEP – Bank/Tax Details Form

Please return this form (and your Payment of Teacher Allowance form) to: PEP Administration Officer ACU National, PO Box 456, Virginia QLD 4014 Email: FEA.PlacementsQLD@acu.edu.au

POSITION:

SCHOOL NAME: SURBURB/TOWN:

PERSONAL DETAILS (to be completed by the prospective employee)

Title: Surname: _________ Payment of salary is by Electronic Funds Transfer:

Given names: Bank/Credit Union:

Address: BSB: - Six digits are required

A/C No:

State: __ P/Code:_ _ _ _ Phone: ( ) _____ Please note: If information is incorrect or incomplete payments cannot be processed

Date of Birth: _/ _ /__ Sex: M / F If in doubt contact your banking institution

Have you been employed previously at Australian Catholic University: YES/NO Year: _______

TESS Superannuation Number (if known):

This is to be completed in place of a full TAX FILE NUMBER DECLARATION normally obtainable from the ATO.

(*) Q1 Tax File

Number

or I have lodged a TFN application or I am under 16 years of age or an exemption claimed as a pensioner

(*) Q2 I agree to have my tax file number passed on to my Superannuation fund. Yes No

(*) Q8 Are you an Australian resident for taxation purposes?

If no, you cannot claim the tax-free threshold.

Yes No

(*) Q9 Do you wish to claim the tax-free threshold from Australian Catholic University?

If you have more than one job and you currently claim the tax-free threshold from another payer DO NOT claim it now.

If you have answered NO to this question, rebates cannot be claimed on this form.

Yes No

(*) Q10 & Q11 Rebates and Family Tax Benefits: Are you claiming a family tax benefit through a reduced rate of

withholding? Or a dependant spouse or special rebate? If YES obtain a Withholding

Declaration form.

Yes No

(*) Q12 Do you have an accumulated Higher Education Contribution Scheme (HECS) debt? Yes No

(*) Please refer to the Tax File number declaration form available from ATO. Any questions you may have should be directed to ATO.

Signature: ______________________________________ Date: ________________________

OFFICE USE ONLY Cost Account Number: 5116 51400 D2036

Pay Due

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