AIOH Membership Endorsement

Name

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Original Random

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Original Random

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New Random

You have been nominated to provide a reference for the following candidate:

Please confirm if you wish to be a referee for this applicant.

Do you wish to proceed?(Required)

YES

Your Details

Your Name

First Last

Your Email Address

Your AIOH Status(Required)

Full Member

Fellow

Other (please specify)

Other - please specify(Required)

Work Field / Area of Practice(Required)

Relationship to Applicant(Required)

Colleague

Supervisor

Mentor

Contractor

Other

Other - please specify(Required)

How long have you known the applicant (in years)?(Required)

Nature of Work Relationship(Required)

Direct day-to-day work

Project-based

Contracted services

Other

Other - please specify(Required)

You endorsing the applicant for(Required)

Provisional Membership

Full Membership

Applicant Details

Occupational Hygiene Skills & Experience

Please select the appropriate option and provide examples where relevant.

Exposure Assessment(Required)

Present

Not Observed

Comments / Examples

Risk evaluation & control(Required)

Present

Not Observed

Comments / Examples

Hazard identification(Required)

Present

Not Observed

Comments / Examples

Monitoring & measurement techniques(Required)

Present

Not Observed

Comments / Examples

Technical reporting / documentation(Required)

Present

Not Observed

Comments / Examples

Communication of findings(Required)

Present

Not Observed

Comments / Examples

Fieldwork / site assessments(Required)

Present

Not Observed

Comments / Examples

Application of professional judgment(Required)

Present

Not Observed

Comments / Examples

Project or team leadership(Required)

Present

Not Observed

Comments / Examples

Professional Competency Assessment

Please select the appropriate option and provide examples where relevant.

Demonstrates sound technical knowledge(Required)

Satisfactory

Needs Development

Comments / Evidence

Applies principles of occupational hygiene effectively(Required)

Satisfactory

Needs Development

Comments / Evidence

Manages complex or varied hygiene scenarios(Required)

Satisfactory

Needs Development

Comments / Evidence

Collaborates with peers and stakeholders professionally(Required)

Satisfactory

Needs Development

Comments / Evidence

Demonstrates continuous learning / CPD(Required)

Satisfactory

Needs Development

Comments / Evidence

Ethics & Professional Conduct

Please select the appropriate option and provide examples where relevant.

The applicant upholds the high ethical and professional standards expected by the AIOH(Required)

Agree

Disagree

Comments (if any)

The applicant is respectful, trustworthy, and accountable in their professional conduct(Required)

Agree

Disagree

Comments (if any)

You are aware of any ethical or professional concerns that would affect their application(Required)

YES

If yes, please explain

Other

Additional comments for applicant

Final Declaration(Required)

I have no conflict of interest in providing this reference. Based on my professional knowledge of the applicant, I have no hesitation in recommending them as a fit and proper person for the endorsed Membership Grade of the Australian Institute of Occupational Hygienists. By signing this document the above information is true and accurate.

Providing false information or declaration may result in applicant and reference member may result in disciplinary action including recommendations to cease AIOH membership.

I agree and digitally sign this submission