Employee/Operator

Competency/Training
Assessment Record

Name: ID No:

Commencement Date: Staff No.:

Part A: Employee Declaration

Past Experience

Dates Type of Plant

Company Position
From To Operated

Declaration

I ID No.: hereby declare that the

details of my past experience given are correct to the best of my knowledge.

Signature: Date:

Form No: Rev No: 0 Page : 1 of 3

 Employee/Operator
Competency/Training
Assessment Record

Part B: Proficiency Test / Training Summary

Proficiency Test

Date Job No. Description of Proficiency Test Result Superintendent

Summary of Training

Date
Duration Job No. Superintendent Type of Training Comment
Commenced

Form No: Rev No: 0 Page : 2 of 3

 Employee/Operator
Competency/Training
Assessment Record

Part C: Employer’s Declaration

Based on the declaration in PART A of this form made by Mr.

ID No.: we confirm that this employee has undertaken a proficiency test and
received training to operate the following plant or operate the plant under supervision.

Employer’s
Date Job No. Type of Plant Superintendent Representative
Signature

Form No: Rev No: 0 Page : 3 of 3