Personal Details/Job Application: Tel: 08 9246 9886 Fax: 08 9246 9883

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PERSONAL DETAILS/JOB APPLICATION
SURNAME: ADDRESS: PHONE: EMAIL ADDRESS: D.O.B: HOBBIES:
GIVEN NAME/S:
MOBILE:
POSITION/TITLE:
DO YOU HAVE A DISABILITY WHICH COULD IMPACT ON JOB SAFETY, ATTENDANCE OR WORK PERFORMANCE IF YES PLEASE DESCRIBE:
YES / NO
PLEASE SUPPLY COPIES OF THE FOLLOWING BLUE CARD WORKING AT HEIGHTS CARD TRADE CERTIFICATE IF APPLICABLE ANY OTHER TICKETS/CARDS/CERTIFICATES RELEVANT TO FORMWORK RESUME - INCLUDING EDUCATION AND EMPLOYMENT HISTORY REFERECES DECLARATION OF APPLICANT 1. I AGREE TO ABIDE BY SAFETY RULES AND REGULATIONS WHICH APPLY 2. I DECLARE THAT THE INFORMATION I HAVE SUPPLIED BY COMPLETING THIS APPLICATION AND DOCUMENTS PROVIDED BY MYSELF ARE TRUE AND CORRECT. ANY FALSE INFORMATION WILL RENDER THE APPLICATION NULL AND VOID OR RESULT IN TERMINATION OF EMPLOYMENT 3. I AGREE TO ALLOW AND AUTHROISE THE COMPANY TO COMPREHENSIVELY CHECK MY WORKERS COMPENSATION HISTORY 4. I UNDERSTAND THAT PART OF THE APPLICATION PROCEDURE INVOLVES A PRE EMPLOYMENT MEDICAL/ HEARING TEST/DRUG TEST AND IS UNDERTAKEN AT THE EMPLOYEES ExPENSE, AND I AUTHORISE DISCLOSURE OF THE RESULTS TO ADVANCE FORMWORK PTY LTD APPLICANTS SIGNATURE: DATE: PLEASE NOTE THAT THIS APPLICATION FOR EMPLOYMENT IS ACCEPTED WITHOUT PREJUDICE AND SHOULD NOT BE CONSIDERED AS AN OFFER OR EMPLOYMENT.
Tel : 08 9246 9886 Fax : 08 9246 9883
POBOX1284,WangaraDC,WA6947 [email protected] w w w. a d v a n c e f o r m w o r k . c o m . a u
PRE-EMPLOYMENT MEDICAL ASSESSMENT
Please answer the following questions regarding your Medical History. Are you being treated by any doctor for any illness or taking any medications for a medical condition? Have you been hospitalised for any illness or had any operations? Is there a family history of any medical conditions? Do you have any Medical Condition(s) that need to be monitored regularly, or medical issues your employer needs to be made aware of to ensure your safety and fitness for work. Is there any reason why you cannot wear safety or protective equipment? Have you ever tested positive in any workplace drug & alcohol-screening test? Do you need to wear glasses for your normal work? If so, do you have prescription safety glasses? Have you any current medical or surgical condition? Have you had any time off work in the last year? Do you have Diabetes? Do you have any known occupational allergies? Do you have or have you ever had any of the following? Lung Problems/Asthma/Bronchitis Suffered Blood Pressure or Heart Trouble Fits/Seizures/Blackouts or Persistent Headaches/Migraines Joint Problems/Fractures or Arthritis/Rheumatism Back or neck problems Any medical condition that prevents you from undertaking manual handling activities? Repetitive Strain/Overuse Injury Mental or nervous troubles Loss of hearing/ear infections Stomach Problems/Ulcers
YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO YES NO
Do you have any difficulty with the following activities? Running 100 meters Walking on rough ground Kneeling Standing for two hours Turning your head rapidly Using hand tools
YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO
YES YES
NO NO
YES
NO
Concentrating for any length of time Hearing a normal conversation
YES
NO
Climbing any ladders Crouching / Squatting Sitting for two hours Lifting or bending Gripping firmly with one or both of your hands Reading ordinary print / text Repetitive movements of the hands or arms Understanding English Understanding Safety Signs
YES YES YES YES YES YES YES
NO NO NO NO NO NO NO
Have you had any exposure to any of the following in your past jobs? Loud noise / explosives Asbestos Chemicals Dust Have you had a hearing test in the last 12 months? Do you have or have you ever had any of the following? Tuberculosis Any strain of Hepatitis/Jaundice/Liver Trouble Any Type of Hernia?
YES YES YES NO NO NO YES YES YES YES YES NO NO NO NO NO
If you answered Yes to any other of the above please provide details here.
Have you had any workers compensation claims in the past or a work related injury or illness? Date of Accident: Name of the EMPLOYER Nature of the INJURY Total days lost (if any): Was a final medical certificate issued? If No, what is the current FITNESS FOR WORK status on the last medical certificate? OFFICE USE ONLY 1)
YES
NO
(If Yes provide details below)
2)
YES
NO
Did the Employee answer Yes to any of the questions in this assessment? ***If Employee answers YES to any question refer immediately to OH&S Officer NO (Employee answered No to all questions) YES: REFER TO OH&S MANAGER (Employee answered Yes to one or more questions) Date Signed: ____________________________
Signed by Operations Manager / Safety Officer: ______________________________________________
Tel : 08 9246 9886 Fax : 08 9246 9883
PO Box 1598 Osborne Park WA 6916 [email protected] w w w. a d v a n c e f o r m w o r k . c o m . a u

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PERSONAL DETAILS/JOB APPLICATION

SURNAME: ADDRESS: PHONE: EMAIL ADDRESS: D.O.B: HOBBIES:

Tel : 08 9246 9886 Fax : 08 9246 9883

PRE-EMPLOYMENT MEDICAL ASSESSMENT

Concentrating for any length of time Hearing a normal conversation

YES YES YES YES YES YES YES

(If Yes provide details below)

Signed by Operations Manager / Safety Officer: ______________________________________________

Tel : 08 9246 9886 Fax : 08 9246 9883

PO Box 1598 Osborne Park WA 6916 [email protected] w w w. a d v a n c e f o r m w o r k . c o m . a u

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