!!!!! Are you applying for Recognition of Prior Learning? If yes, please see your instructor. Y N. Suburb State Postcode Postal Address

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1 Course Enrolment Form Confined Gas Test Space Atmosphere Entry - CS 200 MSAPMOHS200A MSAPMPER217A Work Gas Test safely Atmosphere MSAPMPER202A Observe Permit Work MSAPMOHS217A Gas Test Atmospheres Unique Student Identification Number You must have a USI to complete the enrolment Apply now at Are you applying for Recognition of Prior Learning? If yes, please see your instructor. Y N First Name Surname Other Name Gender M F Title (Mr/ Mrs/ Miss/ etc) Date of Birth Residential Address Number Country of Birth Are you an Australian Resident Y N Are you Aboriginal / Torres Strait Islander Y N Do you speak any language other than English Y N If yes, which language do you speak How well do you speak English Very Well Well Not Well Not at all Will you require assistance Y N Have you successfully completed any of the following qualifications Certificate 1 Diploma Level Are you currently at school Y N Certificate 2 Advanced Diploma or Degree Certificate 3 Bachelor Degree or Higher If yes what year are you in Yr Certificate 4 Other Education What is the highest level of school completed Yr What year did you leave School Do you consider yourself to have a disability Y N Do you require assistance with your disability Y N If you require assistance what assistance is required Please indicate your current employment status Employer Part Time Employee Not Employed Not Seeking Employment Self Employed Casual Employee Unemployed Seeking Full Time Work Full Time Employed Employed Unpaid Family Business Unemployed Seeking Part Time Work Employer Business Name Address Employer Contact Employer Street Suburb State Postcode Postal Address Number Street Suburb State Postcode Home Phone Address Mobile Contact Number **** Please sign the reverse of this form to complete the enrolment process ****

2 Privacy Policy EMS collects personal information from participants to facilitate efficient service provision and meet AVETMISS requirements only. The details below are required as part of the Australian Government Regulatory Requirement for Registered Training Organisations. If you fail to complete all details your enrolment will be invalid and you will be contacted to complete the details prior to your enrolment and any subsequent certification being issued. EMS ensures privacy in the following ways. Information is only collected with the knowledge and consent of individuals. Information is only ever used for the purposes that it is collected and is never sold, distributed or shared to third parties except where required by law or other regulation. EMS ensures that the demographic and other statistical information is not linked to and personal information that can be used to disclose the identity of an individual. The information on this form will be used by EMS, The department of Education and Training (DET) and the National Centre for Vocational Education Research (NCVER) and/or other authorised organisations for the purpose of general student administration, identification, communication, State and National reporting, program monitoring and evaluation. Information provided will be held securely and disposed of securely when no longer needed. You may access, correct or amend your personal details by contacting EMS. Participant Declaration By signing below I agree to the terms and conditions as outlined in the Participant Agreement. A copy of this is available on ems.edu.au. Your instructor will also have a copy you are able to view at your training. Pre Course Study (Where Applicable) Where pre course study is required I declare that all work submitted is my own completed solely by me without assistance. Participant Declaration and Release Disability, Cultural or Impairments. I have discussed with my trainer any disabilities, cultural matters or impairments that may effect my ability to complete this course. I am aware that EMS will make adjustments to the program where ever possible so long as it is not a safety issue to enable you to complete the course. Release note I give permission for EMS to discuss my training progress and results with my employer or other appropriate persons as required by EMS. I give permission for EMS to record evidence of my participation and assessment, in written, verbal and visual (including photographic and video) formats. I also give full ownership of such material to EMS. I acknowledge that I have read the above and understand the information provided. I confirm that this information provided by me is true and correct at the time of completion. PARTICIPANT TO SIGN HERE Participant to Sign Date By signing you acknowledge that you agree to the above Page 2 o

3 Assessment Task 1 Refer to the question paper and place a circle around the correct answer. Refer to If the you question make a paper mistake and or place change a circle your around mind simply the correct cross out answer.if the incorrect you make answer a mistake and circle or change the correct youre answer. mind simply cross out the incorrect answer and circle the correct answer. Example A B C D A B C D 1 A B C D 5 A B C D 9 A B C D 13 A B C D 17 A B C D 2 A B C D 6 A B C D 10 A B C D 14 A B C D 18 T F 3 A B C D 7 A B C D 11 A B C D 15 A B C D 19 T F 4 A B C D 8 A B C D 12 A B C D 16 A B C D 20 T F Question 21 List 3 Hazardous gasses that may be found in a confined space: Question 22 Using the vapour density supplied, identify the following gasses as being lighter or heavier than air: Hydrogen Sulphide (Vapour density 1.17) Is Heavier / Lighter than air. Acetylene (Vapour density 0.9) Is Heavier / Lighter than air. Propane (LPG) (Vapour density 1.5) Is Heavier / Lighter than air. Question 23 List 3 activities or situations that could lead to a contaminated atmosphere: Page 3 o

4 Question 24 List the steps in ventilating a large LPG cylinder in preparation for cleaning: Step 1. Step 2. Question 25 A) What is the gas detector to the right telling us? B) Is it safe to enter the atmosphere? Question 26 Identify the hazardous properties of each gas by joining them with a line: Acetylene Highly Flammable / Explosive Ammonia A simple asphyxiate (Non toxic) Nitrogen Highly toxic in small quantities Hydrogen Sulphide Irritant (causes watery eyes and difficulty breathing) END OF ASSESSMENT TASK 1 Page 4 o

5 Assessment Task 2 Identify and Inspect Atmospheric Monitoring Equipment The candidate correctly identifies the equipment listed below and can explain maintenance, fault finding and storage procedures. The candidate must also be able to rectify basic common faults with the equipment. This may be conducted throughout the course or as a stand during the practical assessment phase. Equipment Comments Gas Detector for Confined Space Entry Correct Calibration Gas for the Gas Detector used Sampling Pump and Hose Assessor must record observations here Gas Detector Filters Battery / Charger Assessment Task 3 Conduct Atmospheric Monitoring The candidate is required to identify, assemble and operate a 4 head gas detector. This will also include challenge testing the unit prior to use. The candidate will then test an atmosphere selected by the assessor and determine whether the atmosphere is safe for confined space entry. The candidate will also be asked to identify the limitations of the gas detectors and maintenance procedures. The Assessor will use verbal questioning to determine the candidates understanding of what different readings would mean such as a high LEL, CO or O2 reading. Element Comments The candidate determines the need to test the atmosphere and conducts pre-operational checks on the gas detector prior to use. This includes challenge testing, checking filters and the procedure for calibrating the detector. All levels are tested from a safe position allowing enough time for the sample to reach the sensors prior to moving the detector or probe. The candidate correctly interprets the readings on the detector, identifies the hazards and knows the limitation for confined space entry. The candidate identifies the limitations of the detectors and what can produce false readings. Assessor must record observations here The candidate can explain the process for rectifying basic faults The candidate can explain the storage and maintenance procedures for the gas detector including service intervals, charging or battery change and type of calibration gas required. Page 5 o

6 Assessment Findings Candidate Feedback (Optional) Candidate Response (Mandatory where written feedback is given) Candidate Signature Overall Findings Theory Assessment Satisfactory Unsatisfactory Practical Assessments Satisfactory Unsatisfactory As a result of the assessment process I have found the participant to be Competent Not Yet Competent I, in my capacity as the nominated assessor declare by signing below that: I have sighted the participants legal proof of identity. I have conducted a fair and reasonable, both summative and formative assessment of the participant as per the requirements of the applicable training packages and associated assessment materials. I have conducted assessment in accordance with the training package and the training and assessment guides. The course was delivered in accordance with the training session plan and guidance material provided by EMS. I have provided the participant with appropriate feedback on their performance during assessment and have provided feedback to the participant as to the results of their assessment tasks. Assessor Name: Signed by Assessor: Date: Page 6 o