Permitted Worker Permit

Important: This form can only be issued in accordance with Permitted Worker Permit Scheme Directions. If it is not issued in accordance with
the Permitted Worker Permit Scheme Directions, it is invalid.

Individuals are not required to carry permits before 11.59pm Wednesday 5 August.

Employer details [“Employer”]

Company name Labour Power
ABN 47 102 195 291
Company address 8 Level 1/28 West Ct, Derrimut VIC 3030
Trading name
[If different to company name]
Permitted industry/activity Manufacturing

Employee details [“Employee”]

Full name Joanna Spyriadis
Date of birth 01 July 1982
Residential address 38 Bernhardt Avenue, Hoppers Crossing VIC 3029
Permitted Role for on-site work Freezer Forklift Driver

Employee work location [If different to company address]

394-400 Lower Dandenong Rd, Braeside VIC 3195

[If more than one, must be accompanied by a log recording each work location, and date and time of attendance]

Signed

Employer Employee
 ..........................................................................................
..........................................................................................
[Employer representative signature]
[Employee signature]

15 AUGUST 2020
15 AUGUST 2020 [Date]
[Date]
By signing this permit, the Employee:
By signing this permit, the Employer confirms compliance with
the Permitted Worker Permit Scheme Directions, including:
 attests that their name, address, work hours, place of
work, and employer, as contained in this Permitted Work
 attests that the workplace is compliant with the directions Permit are true and correct that presenting false,
of the Chief Health Officer and the Occupational Health misleading or fraudulent information may incur penalties;
and Safety Act 2004, all reasonable steps have been, and
will continue to be taken, to maintain a safe working
 acknowledges that the nominated representatives may be
environment for the employee, and has a COVIDSafe contacted if deemed necessary to confirm these details
plan in place; and provides consent to the disclosure and collection of
this information;
 attests that the employer is a Permitted Employer
 understands the wording in this Permitted Work Permit
engaged in providing a Permitted Service;
relating to Diagnosed Persons and Close Contacts and
 attests that the information provided on this permit is a agrees to not attend the Work Premises if either of these
true representation relating to a current employee and terms apply to the Employee's circumstances and will
their employment details; notify the Employer immediately if this occurs; and
 acknowledges that the nominated representatives may be  understands that if they develop symptoms or potential
contacted if deemed necessary to confirm these details; symptoms of COVID-19 they are not to attend or remain
and at the Work Premises and will immediately notify their
employer.
 acknowledges the information provided by the employer in
the Permitted Worker Permit is true and correct, and that
presenting false, misleading or fraudulent information may
incur penalties.

Penalties
Completing this document with false or misleading information may cause you to be in breach of the Permitted Worker Permit Scheme
Directions and liable to penalties up to $19,826.40 (individuals) and $99,132 (bodies corporate).

Hours of work
 Fill in either Table 1 or Table 2, as appropriate for the Employee’s working situation.
 Enter the Employee’s start and finish times for each day of the stage 4 restriction period.
 You do not need to include meal breaks or the total number of hours worked each day.
 Leave days blank or mark with an X when the Employee is not scheduled to work.

Table 1: Full-time employee (or working the same hours each week)

Rostered / scheduled work times

All weeks Mon Tue Wed Thu Fri Sat Sun
[Example only] 8.30–5.00 8.30–5.00 8.30–5.00 X 8.30–5.00 X X
3 Aug 2020 –
13 Sep 2020

Table 2: Part-time or casual employee (or working irregular hours each week)

Rostered / scheduled work times

Wee
k Commencing Mon Tue Wed Thu Fri Sat Sun
X
1 17 Aug 2020 9.00 – 5.00 X 9.00 – 5.00 9.00 – 5.00 9.00 – 5.00 9.00 – 5.00 X
am am am am am
2 24 Aug 2020 X 9.00 – 5.00 X 9.00 – 5.00 9.00 – 5.00 9.00 – 5.00 9.00 – 5.00
am am am am am
 Rostered / scheduled work times
Wee
k Commencing Mon Tue Wed Thu Fri Sat Sun
3 31 Aug 2020 9.00 – 5.00 X X 9.00 – 5.00 9.00 - 5.00 9.00 – 5.00 9.00 – 5.00
am am am am am

4 07 Sep 2020 X 9.00 – 5.00 X 9.00 – 5.00 9.00 – 5.00 9.00 – 5.00 9.00 – 5.00
am am am am am
5 14 Sep 2020 X X 9.00 – 5.00 9.00 – 5.00 9.00 – 5.00 9.00 – 5.00 9.00 – 5.00
am am am am am
6

Statement from the Employer

I declare that the Employer has taken all reasonable steps to avoid the necessity for the Employee to attend the Work Premises, but the
Employer has determined that it is not reasonably practicable for the Employee to work from the premises at which the Employee
ordinarily resides and the attendance of the Employee at the Work Premises is required for the provision of a Permitted Service of:

Manufacturing
[Nominate industry or nature of work undertaken]

Issued by nominated representative of the Employer

Nominated representative Secondary contact
Full name Brooke Horbury Full name Mary Jane Jones
Title / Role National HR Manager Title / Role Supervisor
Phone number (03) 9394 5300 Phone number 0421 599 498

Diagnosed Persons and Close Contacts

If a person is a Diagnosed Person or Close Contact for the purposes of the Diagnosed Persons and Close Contacts Directions (No 8) that
person cannot be provided with a Permitted Worker Permit or permitted to enter or remain upon work premises.

An employer who completes a Permitted Work Permit for a person who is a Diagnosed Person or Close Contact may be in breach of the
Permitted Worker Permit Scheme Directions and liable to penalties.

If an Employee is displaying symptoms or potential symptoms of COVID-19, the Employee must not attend the Work Premises and must
immediately notify the Employer of these symptoms.