Dental Health Services Victoria

Forms and templates

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Forms

If you are unable to locate a particular form or the link to the form is broken, please call x1139 or email the name of the form to web.faults@dhsv.org.au 

Payroll and finance

Autopay form [PDF, 56 KB]

 

General expense reimbursement form [PDF, 236 KB]

Change of details form [PDF, 1.72 MB]

 

Leave application [PDF, 56 KB]

Direct banking authority form [PDF, 41 KB]

 

Mileage and accommodation reimbursement [PDF, 47KB]

Fortnightly timesheet [PDF, 116 KB]

  

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Staff matters
Car park application [PDF, 31 KB] 

Reference check - employment and professional [DOC, 86 KB]

Advice of termination (resignation) [PDF, 43 KB] recently updated - 31 March 2011 

Scope of clinical practice application form [PDF, 517 KB]

Termination of employment clearance form [PDF, 88KB]

 IT services account request [DOC, 247KB] 

ID, Proximity card and Key request [PDF, 120 KB]

 Data analysis report request form [DOC, 171KB]

Professional development application [PDF, 79 KB]

 Reimbursement claim form (remunerator website)

Salary packaging application (remunerator website)

 Photographic shoot agreement form [PDF, 200KB]
Employee repackage advice form (remunerator website) Commuter club application for annual myki pass [DOC, 32KB] 
Accident claim form  [PDF, 230KB]  

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Work Health & Safety
Hazard Risk Assessment Form [DOC, 76 KB] Risk Profile Checklist [DOC, 157KB]
Hazardous Manual Task Checklist [DOC, 3.35MB]   VHIMS Incident Flowchart [DOC, 31KB]
Plant Equipment Hazard Checklist [DOC, 3.37MB] Work Health & Safety Hazard Checklist [DOC, 49.5KB]
Work Health & Safety Agreement and Checklist for Working at Home [DOC, 361KB] Workplace Health & Safety Inspections Checklist [DOC, 4MB]

 

 

 

 

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Safety and medical
Staff immunisation history [PDF, 51 KB] Staff immunisation request form [PDF, 50KB]
Code blue form [PDF, 57 KB]   For reporting clinical incidents and hazards, please use VHIMS
Security incident or breach report [DOC, 212 KB]  

 

 

 

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Patient access and referrals
FOI Application Form [PDF, 48 KB] 

General Anaesthetic Patient Health Questionnaire [PDF, 53KB]           

Specialist Services referral form [PDF, 49 KB]

 

Special Needs Dentistry application [PDF, 53 KB]

Special needs dentistry application - schools [PDF, 262 KB]

 

Special Needs Domiciliary application [PDF, 60KB]

Orthodontic referral form [PDF, 45 KB]

 Public Advocate Form / 42K Form [PDF, 516KB] New Form

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Equipment and supplies

Capital asset request form [DOC, 170KB]

 

Online ordering registration [DOC, 233KB]

Capital Asset Request - Urgent [DOC, 155KB]

 

Online ordering registration amendment [DOC, 220KB] 

Capital procedure submission - Business case [DOC, 212KB]

 Asset Disposal Approval Form [DOC, 1.88MB]

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Governance, probity and compliance

 Conflict of interest declaration form [PDF, 234KB]

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Product Evaluation and Technology Assessment Group (PETAG)
Material equipment application form [PDF, 24 KB]
PETAG individual patient usage drug application [PDF, 52 KB]
Pharmaceuticals formulary application form [PDF, 20KB]