Carer Visa Assessment Form ( Bupa Application) Examinee / Resident DetailsFirst NameField is required!Field is required!Last NameField is required!Field is required!Your E-mail AddressField is required!Field is required!SexMaleFemaleField is required!Field is required!Date of BirthField is required!Field is required!Date of arrival in AustraliaField is required!Field is required!Daytime telephone numberField is required!Field is required!Mobile phone numberField is required!Field is required!Address...Field is required!Field is required!- select your country -Åland IslandsAfghanistanAlbaniaAlgeriaAmerican Samoa (US)AndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermuda (UK)BhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurma (Myanmar)BurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook Islands (NZ)Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor-Leste)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (UK)Faroe Islands (Denmark)FijiFinlandFranceFrench GuianaFrench Polynesia (France)GabonGambiaGeorgiaGermanyGhanaGibraltar (UK)GreeceGreenland (Denmark)GrenadaGuam (US)GuatemalaGuernsey (UK)GuineaGuinea-BissauGuyanaHaitiHondurasHong Kong (China)HungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of Man (UK)IsraelItalyIvory CoastJamaicaJapanJersey (UK)JordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau (China)MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMayotte (France)MexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueNamibiaNauruNepalNetherlandsNew Caledonia (France)New ZealandNicaraguaNigerNigeriaNiue (NZ)Norfolk Island (Australia)Northern Mariana Islands (US)NorwayOmanPakistanPalauPalestinian territoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn Islands (UK)PolandPortugalQatarRéunion (France)RomaniaRussian FederationRwandaSão Tomé and PríncipeSaint Helena, Ascension and Tristan da Cunha (UK)Saint Kitts and NevisSaint LuciaSaint Pierre and Miquelon (France)Saint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen (Norway)SwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelau (NZ)TongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna (France)Western SaharaYemenZambiaZimbabwe- select your country -Field is required!Field is required!CityField is required!Field is required!ZipcodeField is required!Field is required! Have you undergone a previous assessment/examination for a Carer visa application?YesNoField is required!Field is required!Date[{"field":"option_6","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!About the person you are asking to come to, or remain in Australia, as a carer Personal details of the personFirst NameField is required!Field is required!Last NameField is required!Field is required!Date of BirthField is required!Field is required!- Country of Residence -Åland IslandsAfghanistanAlbaniaAlgeriaAmerican Samoa (US)AndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermuda (UK)BhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurma (Myanmar)BurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook Islands (NZ)Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor-Leste)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (UK)Faroe Islands (Denmark)FijiFinlandFranceFrench GuianaFrench Polynesia (France)GabonGambiaGeorgiaGermanyGhanaGibraltar (UK)GreeceGreenland (Denmark)GrenadaGuam (US)GuatemalaGuernsey (UK)GuineaGuinea-BissauGuyanaHaitiHondurasHong Kong (China)HungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of Man (UK)IsraelItalyIvory CoastJamaicaJapanJersey (UK)JordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau (China)MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMayotte (France)MexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueNamibiaNauruNepalNetherlandsNew Caledonia (France)New ZealandNicaraguaNigerNigeriaNiue (NZ)Norfolk Island (Australia)Northern Mariana Islands (US)NorwayOmanPakistanPalauPalestinian territoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn Islands (UK)PolandPortugalQatarRéunion (France)RomaniaRussian FederationRwandaSão Tomé and PríncipeSaint Helena, Ascension and Tristan da Cunha (UK)Saint Kitts and NevisSaint LuciaSaint Pierre and Miquelon (France)Saint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen (Norway)SwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelau (NZ)TongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna (France)Western SaharaYemenZambiaZimbabwe- Country of Residence -Field is required!Field is required!What is your relationship with this person?Field is required!Field is required!Please name all persons who will be coming with the main carer (i.e. other family members migrating with them)NameField is required!Field is required!RelationshipField is required!Field is required!Has this person already lodged the carer visa application with Department of Home Affairs?YesNoField is required!Field is required!Receipt number[{"field":"field_TRfCZ","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Date[{"field":"field_TRfCZ","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Your current situationWhat is your current situtation？ Field is required!Field is required!What are your main medical conditions that result in your need for extra assistance?Field is required!Field is required!Who currently helps you with activities requiring extra assistance?NameField is required!Field is required!AgeField is required!Field is required!RelationshipField is required!Field is required!Do you require assistance in the following areas?Bathing and showering (e.g. washing, help in and out of the bath or shower)Toileting (e.g. help getting on or off the toilet, cleaning up incontinenceDressing, undressing and grooming (e.g. haircare, shaving, dental care, help with zips or buttons, help with drawers/wardrobes, fitting prostheticsEating (e.g. assisting with feeding and cooking, holding straws, cutting up food, preparation of special diet)Mobility (e.g. walking, pushing the wheelchair, assisting with stairs, moving in and out of bed or turning)Special exercise therapyTransportation because of disability (e.g. to physiotherapy, to medical appointments)Preparing or supervising medication (e.g. sterilising equipment, changing dressings, care of prosthetics)Field is required!Field is required!Time taken each day to provide the assistance in Bathing and showeringLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option}","logic":"contains","value":"1","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Time taken each day to provide the assistance in ToiletingLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option}","logic":"contains","value":"2","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Time taken each day to provide the assistance in Dressing, undressing and groomingLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option}","logic":"contains","value":"3","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Time taken each day to provide the assistance in EatingLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option}","logic":"contains","value":"4","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Time taken each day to provide the assistance in MobilityLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option}","logic":"contains","value":"5","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Time taken each day to provide the assistance in Special exercise therapyLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option}","logic":"contains","value":"6","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Time taken each day to provide the assistance in Transportation because of disabilityLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option}","logic":"contains","value":"7","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Time taken each day to provide the assistance in Preparing or supervising medicationLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option}","logic":"contains","value":"8","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Is constant supervision required in the following areas?Monitoring/supervision – during the night (e.g. administering timed medications, ensuring you do not wander off)Monitoring/supervision – during the day (e.g. ensuring that you do not wander off, ensuring that gas/stove/taps are turned off, preventing other unsafe behaviour)Field is required!Field is required!Time taken each day to provide the assistance in Monitoring/supervision – during the nighLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option_2}","logic":"contains","value":"1","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Time taken each day to provide the assistance in Monitoring/supervision – during the dayLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option_2}","logic":"contains","value":"2","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Do you have other assistance or supervision required – please specify?YesNoField is required!Field is required!Ask us other assistance or supervision required...Field is required!Field is required!Time taken each day to provide this assistanceLess than 30 minutes30-60 minutes60-120 minutesMore than 120 minutes[{"field":"{option_2}","logic":"equal","value":"2","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required![{"field":"option_3","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]What are your current assistance arrangements? Who looks after you? How often? For what length of time?Field is required!Field is required!Who is the doctor you usually see about your illness/disabilities?Name of doctorField is required!Field is required!Address of doctorField is required!Field is required!Contact TelephoneField is required!Field is required!Has a specialist or another doctor/specialist treated you for these illnesses/disabilities?YesNoField is required!Field is required!Name of specialist/consultantField is required!Field is required!Address of specialist/consultantField is required!Field is required!Date of last visitField is required!Field is required!Conditions for which you were treatedField is required!Field is required!If you need to give more information, please use the space.Field is required!Field is required![{"field":"option_4","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]Is there anybody else who could tell us about any of your illnesses/disabilities? (e.g. Psychologist, physiotherapist, counsellor, community worker)YesNoField is required!Field is required!Name of other practitionerField is required!Field is required!ProfessionField is required!Field is required!Address of personField is required!Field is required!Contact TelephoneField is required!Field is required!If you need to give more information, please use the space.Field is required!Field is required![{"field":"field_bJSQz","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]Have you ever been admitted to hospital for treatment of these illnesses/disabilities?YesNoField is required!Field is required!Date of last admissionField is required!Field is required!Discharge date of last admissionField is required!Field is required!Name of hospitalField is required!Field is required!Reason for admission (e.g. operation, investigation, treatment)Field is required!Field is required!Number of hospital admissions in the last five yearsField is required!Field is required![{"field":"field_aCgaO","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]If you need to give more information, please use the space.Field is required!Field is required!提交
