Pre-Employment Medical Form

CHECKLIST

Which division of JBS did you apply for employment with? (PLEASE CIRCLE)

Meat Processing FoodPartners Brisbane Office Feedlots Cold Stores /

Distribution Centres

APPLICANT TO COMPLETE:

Part A – Applicant Medical Information

∙ Musculoskeletal Condition
∙ Personal Details
∙ Movement Function
∙ General Medical History
∙ Consent for Alcohol & Other Drugs Testing
∙ Specific Medical History
∙ Acknowledgement
∙ Cardiovascular Function & Physical Fitness
∙ Drugs & Medications

EXAMINER TO COMPLETE:

Part A - Comments on Part A Medical Examination

Part B - Examinee’s Details & Examination Results

Part C - Conclusions of Medical Examination

APPENDIX A: Q FEVER TESTING / VACCINATION

Meat Processing FoodPartners Brisbane Office Feedlots Cold Stores /

(ex. Tasmania) Distribution Centres

COMPULSORY FOR ALL APPLICANTS WITHIN 3 NOT REQUIRED

MONTHS OF
COMMENCEMENT

GENERAL INFORMATION FOR APPLICANTS

Please answer all questions carefully.

If you do not understand any questions, please ask the Nurse or Doctor for help.

PRIVACY NOTE
The health information collected via this Pre-Employment Medical Form and your Pre-Employment Medical Consultation is
considered sensitive personal information pursuant to the Privacy Act 1988 (Cth). Please read the Privacy Policy on display in
this office for information about our uses and disclosure of this information. Please note that your health information may be
disclosed to the Human Resources Department and Management during the recruitment process and the course of
employment if your application is successful whether your health information is derived from your pre employment medical
examination or subsequent consultations. All health information will be treated as confidential.

Interpreter Details

Was an interpreter required? • Yes No

Please circle JBS Employee / Labour Hire Representative / Other Print Interpreter Name

Interpreter Employee ID (for JBS Employees only)

Interpreter Contact Number

Signed Interpreter _ Date

REC05.3 Pre Employment Medical V10.1 20201130 1

Pre-Employment Medical Form

PART A – APPLICANT MEDICAL INFORMATION
You will be taking part in a functional assessment that will be physically demanding.

PERSONAL DETAILS
Do you have any medical condition(s) that may affect your ability to perform the tests safely today?

Surname Given Name(s)

☐ No ☐ Yes Details: Mbajang

First Name Joshua Renaldo Surname Joshua

Date of Birth 02/07/1998 Height & Weight 175cm 66kg

Address 19 saltaire drive, strathtulloh, vic, Post Code 3338

Mobile Number +61 412 823 536 Home Number

Email [email protected]

Are you ☐ Right Handed ☐ Left Handed ☐ Ambidextrous

Please answer Yes or No to the following questions.

For all questions answered yes please provide details in the Further Information section located at the end of this
form.
GENERAL MEDICAL HISTORY – PLEASE TICK YES OR NO Yes No

1 Have you had a pre-employment medical examination with any JBS site before?

2 Do you suffer from any ongoing or recurring injury/illness that results in frequent or prolonged time
off work?

3 Are you restricted from any activities (e.g. heavy exercise, driving) because of medical reasons?
4 Have you had a hospital admission, operation, serious accident, injury or illness in the last 10
years?

5 Does any health problem restrict your activities of daily living?

6 Do you have any allergies (e.g., hay fever, food products, chemicals or medication)?

7 Do you suffer from any condition that requires regular medical review or time away from work for
treatment or rest?

8 Have you ever had an injury, illness or condition, resulting from work?

9 Have you ever made a claim for worker’s compensation in any previous employment within this
state or any other state in Australia?

10 Have you ever been regularly exposed to any hazards such as:
Chemicals / Noise / Heavy metals / Asbestos /Radiation / Other?

SPECIFIC MEDICAL HISTORY – PLEASE TICK YES OR NO Yes No

Have you had or suffered or do you have a family history any of the following?

12 Cancer, Tumour

13 Varicose Veins, Blocked Arteries, Clots, Blood Disorder

REC05.3 Pre Employment Medical V10.1 20201130 2

Pre-Employment Medical Form

14 Hernia

15 Blackouts, Fits, Faints, Epilepsy, Spasms, Dizziness, Giddiness

16 Persistent or severe Headaches, Migraines

17 Head Injury, Brain Injury, Concussion

18 Arthritis, Rheumatism, Other Joint Illnesses

19 Stomach Ulcers, Indigestion, Pancreatitis, Bowel Problems, Other Abdominal Disorders

20 Kidney Problems, Overactive or Underactive Thyroid Gland, Bladder Problems

21 Migraines or frequent headaches.

22 Nervous Disorder, Claustrophobia, Depression, Anxiety, PTSD, Other Stress Related Disorders

23 Are you currently experiencing above average stress or difficulties at home?

24 Eczema, Psoriasis, Dermatitis, Other Skin Disorders

25 Diabetes, High Cholesterol

26 Degenerative diseases/disorders Consultations or treatment by any medical or surgical specialists?

27 Bowel disease/disorder, severe or frequent abdominal pain, diarrhoea or blood in bowel motions
(e.g. irritable bowel syndrome (IBS), ulcerative colitis, Crohn’s disease, recurrent gastroenteritis)

28 Piles/haemorrhoids, anal or rectal condition (e.g. rectal prolapse, anal abscess/fissures/sinus)

29 Eye disease/disorder, eye injury/surgery (e.g. glaucoma, cataracts, foreign body or trauma, lazy
eye/squint/double vision)

30 Eyesight problem (e.g. blindness, need for glasses/contacts, colour blindness, visual field loss)

31 Ear disease/disorder, ear injury/surgery (e.g. chronic or recurrent ear infections or discharge,
eardrum perforation, grommets)

32 Hearing problem (e.g. deafness, hearing loss, severe ringing in ears/tinnitus)

33 Nose/sinus disease/disorder (e.g. chronic or recurrent hay fever, sinusitis, severe nose bleeds)

34 Chronic fatigue syndrome, post-viral syndrome, fibromyalgia

CARDIOVASCULAR FUNCTION / PHYSICAL FITNESS – PLEASE TICK YES OR NO Yes No

35 Have you ever suffered from:

Heart Disease, Heart Attack, Stroke, High Blood Pressure, Heart Palpitations or any other heart
illnesses?

36 Has your doctor ever said that you should only engage in physical activity recommended by a
doctor?

37 Is your doctor currently prescribing drugs (e.g., aspirin) for your blood pressure or heart condition?
REC05.3 Pre Employment Medical V10.1 20201130 3

Pre-Employment Medical Form

38 Do you ever feel pain in your chest when you engage in physical activity?

39 Do you lose your balance because of dizziness, or do you ever lose consciousness when engaging in
physical activity?

40 Do you exercise / play sport?

If yes: What is the activity / how often e.g. 20 mins per day three times per week (Mini Soccer araount 30-40 minutes)

41 Do you have any other recreational interests?

42 Do you know of any other reason why you should not engage in physical activity?

43 Have you ever suffered from:

Asthma, Bronchitis, Pneumonia, Pleurisy, Emphysema, Tuberculosis, Industrial Lung Disease or
other respiratory disorders?

44 Do you experience shortness of breath when resting?

45 Do you experience shortness of breath with minimal exercise such as walking up a slight hill?

46 Do you ever wake during the night with shortness of breath or a wheeze?

47 Have you ever had attacks of shortness of breath or wheezing?

48 Does your chest ever feel tight or your breathing become difficult?

DRUGS & MEDICATION– PLEASE TICK YES OR NO Yes No Details

49 Are you a current smoker or ex-smoker? Current cigarettes

smoked per day

50 Do you consume alcohol? Alcoholic drinks per day

/ per week _

51 Are you currently taking any prescription medication? Type:

52 Are you currently taking any non-prescription medication or remedies? Type:

53 Do you use illegal drugs regularly (e.g. cannabis, speed etc.)? Type:

MUSCULOSKELETAL CONDITION Yes No

NECK

54 Have you ever injured or experienced pain in your neck?

If yes, please complete questions below.

Approximate date occurred ADDITIONAL INFORMATION

Did you consult a medical practitioner? ☐ No ☐ Yes

Did it result in time off work? ☐ No ☐ Yes

Was surgery required? ☐ No ☐ Yes

Is it an ongoing problem? ☐ No ☐ Yes

REC05.3 Pre Employment Medical V10.1 20201130 4

Pre-Employment Medical Form

BACK

55 Have you ever injured or experienced pain in your

back?
If yes, please complete questions below.

Approximate date occurred ADDITIONAL INFORMATION

Did you consult a medical practitioner? ☐ No ☐ Yes

Did it result in time off work? ☐ No ☐ Yes

Was surgery required? ☐ No ☐ Yes

Is it an ongoing problem? ☐ No ☐ Yes

SHOULDERS, ELBOWS, WRISTS & HANDS

56 Have you ever injured or experienced pain in your shoulder, elbows, wrists & hands? (i.e.
sprain/strain/fracture/tendonitis/epicondylitis/ carpal tunnel syndrome etc)
If yes, please complete questions below.

Approximate date occurred Around 10 year ago ADDITIONAL INFORMATION

 Did you consult a medical practitioner? ☐ No ☐ Yes

Did it result in time off work? ☐ No ☐ Yes

Was surgery required? ☐ No ☐ Yes

Is it an ongoing problem? ☐ No ☐ Yes

HIPS, KNEES, ANKLES, LEGS & FEET

57 Have you ever injured or experienced pain in your hips, knees, ankles, legs & Feet? (i.e.
sprain/strain/fracture/tendonitis etc).
If yes, please complete questions below.

Approximate date occurred 8 years ago ADDITIONAL

INFORMATION

Did you consult a medical practitioner? ☐ No ☐ Yes

Did it result in time off work? ☐ No ☐ Yes

Was surgery required? ☐ No ☐ Yes

Is it an ongoing problem? ☐ No ☐ Yes

58 Numbness or tingling in the hands or feet on a frequent basis?

59 Any other condition of the muscles, bones or joints including sprains, strains or dislocations?

MOVEMENT FUNCTION– PLEASE TICK YES OR NO Yes No

60 Do you have any pain or discomfort when lifting or handling heavy objects?

61 Do you have any knee pain when squatting or kneeling?

62 Do you have any back pain when bending forward or twisting?

REC05.1 Pre Employment Medical V07.1 20150917 5

Pre-Employment Medical Form

63 Do you have any pain or difficulty when lifting objects above your shoulder height?
64 Do you have any pain when doing any of the following for PROLONGED PERIODS?
(please circle appropriate response)
Yes / No
Walking
Yes / No
Yes / No
Standing
Sitting
Yes / No
Bending
Yes / No
Yes / No
Climbing
Kneeling
Yes / No
Squatting

65 Do you have any pain when using a gripping motion?

66 Do you experience any difficulty operating machinery?

67 Do you have any problems working in:

Hot dry conditions, Humid conditions, Cold conditions, Wet conditions?

68 Do you have problems working at heights?

69 Is there any reason why you cannot wear safety or protective equipment (e.g., safety boots, ear
muffs or plugs, gloves, safety glasses or hard hat)?

70 Do you anticipate that you will require assistance, in the form of specific aids or task modification?

FOR FEMALE APPLICANTS ONLY

PLEASE TICK YES OR NO Yes No

69 Do you have or have you recently had menstrual / gynaecological disease / disorder / surgery (e.g.
severe painful periods, excessive bleeding, endometriosis, fibroids, hysterectomy, or caesarean)?

ALL APPLICANTS

Please specify any other condition not mentioned above that could be relevant to your satisfactory work performance or
attendance: After reviewing the conditions provided, I don't have any additional specifications to include at this time.

ALL APPLICANTS
For all questions answered yes, please provide further information.

• My father has a history of high cholesterol, and he still needs to take medication occasionally.
• I suffer from nearsightedness, requiring me to wear glasses to see objects or things that are far away.
• I engage in regular exercise, usually playing futsal, mini soccer, or simply jogging.
• I have experienced shortness of breath while resting, usually after pushing myself to my maximum limit during
running. Initially, my breath may be short, but it returns to normal after a brief rest.
• I sustained a minor injury to my finger about 10 years ago, but it didn't require medical attention.
• I also had an ankle injury about 8 years ago, which was accidental and occurred during exercise. However, it
only took 1-2 weeks to recover, and everything returned to normal.

REC05.2 Pre Employment Medical V10.2 20201130 6

Pre-Employment Medical Form

PLEASE PRINT YOUR NAME & SIGN BELOW IF YOU ARE BEING EXAMINED BY THE SOFT TISSUE CENTRE

Applicant Name: Joshua Renaldo Mbajang

Signature: Date: 29/02/2024

STC Provider Name:

Signature: Date:

REC05.2 Pre Employment Medical V10.2 20201130 7

Pre-Employment Medical Form

ALCOHOL & OTHER DRUGS TESTING CONSENT FORM

STEP 1 – TO BE COMPLETED BY DONOR

Name

DOB

Site

Position JOB APPLICANT

 I consent to the provision of a sample of my oral fluid and/or my breath, and to the testing of my oral fluid and/or a sample
of my breath as provided.
I understand that if I decline to sign this consent and decline to take the test, my application for employment may be
rejected or my employment with the Company may be terminated or I may be refused entry to the Company Site.

Prescription or Over the Counter Drugs - Disclosure during the Testing Process

Prior to providing a saliva or breath sample the Donor shall disclose any Drug use to the Trained Officer. The onus is on
the Donor to declare Drug use at the time of providing a sample to the Trained Officer. Drug use is not able to be
retrospectively declared.

The Donor is not required to state his or her medical condition but should be advised that certain prescription
Drugs may return a Positive Result during testing.

The Trained Officer shall provide to the Donor a copy of the list of common over-the-counter and prescription Drugs
which may lead to a Non-Negative Result. Please refer to list over page.

I hereby declare that I am currently taking the following prescription or non-prescription drugs or medications,
which may affect the results of a drug or alcohol test.

Name of the Drug:

Agreed Signature: Date:

Refused Signature: Date:

Parent / Legal Signature: Date:

Guardian
(if a minor)

REC05.2 Pre Employment Medical V10.2 20201130 8

Pre-Employment Medical Form

List of common over-the-counter and prescription Drugs which may lead to a Non-Negative Result
This list is a guide only

Opiates (Codeine/Morphine) Amphetamine Type

Actacode Liquigesic Actifed Logicin Sinus Tablet
Anamorph Mersyndol Benadryl Mucotuss
Aspalgin Mersyndol Forte Biotech Cold and Flu Nucosef
Biotech Cold and flu Morphalgin Chlorpromazine Nurofen Cold and Flu
Codalgin MS Contin Codral Cold and Flu Orthoxicol Cold and Flu
Codalgin Forte Naltrexone Cold and Flu Panadol Allergy sinus
Codapane Nucosef Demazin Cold and Flu Panadol Cold and Flu
Codeine Phosphat Nurofen Plus Dexamphetamine Panadol Sinus
Codipehn Ordine Dexolox Phensedyl
Codis Painstop Syrup Dimetapp Phescode
Codral Panadeine Dur-elix Quinine
Codral dry cough Panadeine Forte Duro-tuss Robitussin
Codral Forte Panalgesic Lemsip Pharmacy Flu Sinus Pain Relief
Disprin Forte Panamax Linctus Sinutab
Durotuss Paracetamol Logicin Cough Sudafed
Dymadon Pholcodine suppressant Logicin Tri-profen
Dymadon Forte Pholcodine Hay Fever Tylenol Allergy Sinus
Fiorinal Prodeine-15 Zyban
Kapanol Tixylix
Linctus Veganin

STEP 2 – TO BE COMPLETED BY TESTING PERSONNEL

I certify that the sample identified on this form is that provided to me by the Donor named on this form who has also
provided consent and I have analysed the sample.

I certify that I have sighted Photo Identification of the Donor named on this form or have identified them by
other means.

Test ID: Not required. Sample Type: ☐ Saliva ☐ Breath

Has the donor consumed food / drink / cigarettes within the last 10 minutes? ☐ Yes ☐ No

Collection Site: Breathalyser Device ID:

Saliva Test Batch Number: Saliva Test Expiry Date:

Collector Name: Date of Collection:

Signature: Time of Collection:

STEP 3 – TO BE COMPLETED BY TESTING PERSONNEL

Alcohol Initial Result: Time:

Second Result: Time:

 Other Drugs Initial Test Second Test
Amphetamine (AMP) ☐ Negative ☐ Non-Negative ☐ Negative ☐ Non-Negative
Cocaine (COC)
☐ Negative ☐ Non-Negative ☐ Negative ☐ Non-Negative
Methamphetamine (METH)
Opiates (OPI) ☐ Negative ☐ Non-Negative ☐ Negative ☐ Non-Negative
Cannabinoids (THC) ☐ Negative ☐ Non-Negative ☐ Negative ☐ Non-Negative
☐ Negative ☐ Non-Negative ☐ Negative ☐ Non-Negative

Follow-up Action Required ☐ None, this drug test provided a Negative Result
☐ Confirmatory test required

Chain of Custody This original document must accompany any specimen(s) dispatched for
laboratory testing and be sealed inside the specimen bag.

REC05.2 Pre Employment Medical V10.2 20201130 9

Pre-Employment Medical Form

ACKNOWLEDGEMENT
PLEASE READ THE FOLLOWING AND SIGN IN THE PRESENCE OF THE EXAMINER

Please provide the details of your usual Doctor (GP), Specialist or Medical Clinic you attend.

Name of Doctor / Clinic

Address of Doctor / Clinic

Contact Phone Number

Do you give permission for your current or previous Doctors or Specialists to provide further details of your medical history
if required? ☐ Yes ☐ No

1. The Applicant/Employee authorises the Employer to disclose the Applicant’s/Employee’s personal information where it is
deemed necessary by the Employer or if required by law.

2. I acknowledge and accept as a condition of my employment that if any of the information supplied by me in this medical
questionnaire is found to be incorrect, incomplete or misleading I will be liable to instant dismissal without prejudice
to JBS.

Applicant Signature: Date:

Examiner Signature: Date:

The following is to be completed by the EXAMINING PRACTITIONER only:

COMMENTS ON PART A OF MEDICAL EXAMINATION:

Provide comments on positive responses from the above medical history including details of the severity of the
condition and the extent to which it is controlled.
REC05.2 Pre Employment Medical V10.2 20201130 10

Pre-Employment Medical Form

PART B: EXAMINEE’S DETAILS & EXAMINATION RESULTS

APPLICANT DETAILS

Surname Given Name(s)

Date of Birth Gender ☐ Male ☐ Female

JBS Site Date of Examination

PRE-EXAMINATION RESULTS: (TO BE COMPLETED BY THE EXAMINING NURSE/DOCTOR)

Height (m) Weight (kg)

Grip Strength Left Right Colour Vision ☐ Pass ☐ Fail

(Ishihara Test)

Distance Vision Unaided Right Eye / Aided Right Eye /

Left Eye / Left Eye /

1. Blood Pressure FIRST READING: / SECOND /

READING: (IF
INDICATED)

PLEASE TICK THE APPROPRIATE COLUMN

2. Body Mass UNDERWEIGH NORMAL OVERWEIGH OBESE MORBIDLY

Index (BMI) T (BMI < 20) (BMI 20 – 25) T (BMI 25 – (BMI 30 – 40) OBESE
Wt(kg)/Ht(m)2 30) (BMI > 40)

(WNL = WITHIN NORMAL LIMITS SCA = SIGNIFICANT CLINICAL ABNORMALITY) WNL SCA

3 Cardiac System

4 Vascular System

5 Respiratory System
6 Abdomen – (including herniae)

7 Cervical Spine

8 Thoracolumbar / Sacral Spine

9 Upper Limbs – (including shoulders, elbows, wrists, hands-strength, dexterity)

10 Lower Limbs – (including hips, knees, ankles, feet-strength, mobility)

11 General Musculoskeletal System

12 Neurological System – (including coordination and balance)

13 Skin – (including significant dermatitis, infective lesions)

14 Endocrine System

15 Lymph Nodes

16 Ear, Nose and Throat

17 Hearing / Speech – (including clinical evidence of communication impairment)

18 Eyes – (including clinical evidence of visual impairment)

19 Mental State – (including cognitive, psychiatric and behavioural impairment)

REC05.2 Pre Employment Medical V10.2 20201130 11

Pre-Employment Medical Form

The following is to be completed by the EXAMINING PRACTITIONER only:

COMMENTS ON PART B OF MEDICAL EXAMINATION:

Provide comments on any significant clinical abnormalities including the severity of the abnormality and the extent to
which it is controlled.
IS FURTHER MEDICAL INFORMATION REQUIRED PRIOR TO A FINAL ASSESSMENT?

☐ NO – PROCEED TO PART C

☐ YES – DETAIL WHAT FURTHER INFORMATION OR ACTION IS REQUIRED:

Examiner Name

Examiner Signature: Date:

COMMENTS AFTER REVIEW OF ADDITIONAL INFORMATION OBTAINED: (IF INDICATED)

REC05.2 Pre Employment Medical V10.2 20201130 12

Pre-Employment Medical Form THIS SECTION IS TO BE

PHOTOCOPIED AND SENT TO RECRUITMENT OFFICE

PART C: CONCLUSIONS FROM MEDICAL EXAMINATION

APPLICANT DETAILS

Surname Given Name(s)

Date of Birth Gender ☐ Male ☐ Female

JBS Site Date of Examination

Q FEVER STATUS

The applicant’s Q fever status has been finalised, and the applicant;

☐ Was vaccinated for Q fever today ☐ Has previously been vaccinated for Q fever

☐ Is determined to have positive immunity ☐ Is awaiting Q fever screening

CONCLUSION OF MEDICAL EXAMINATION

Taking into consideration the results of Pre-Employment Medical Parts A and B, I am of the opinion that:
(please tick as appropriate)
☐ This examinee is fit and capable, from a medical perspective, to work in any position, and perform any range of work
within the;

☐ Meat processing industry, and is considered to be free from any impediment that precludes them
from handling meat products.
☐ Food processing industry, and is considered to be free from any impediment that precludes them
from handling food products.
☐ Feedlot industry
☐ Distribution industry

☐This examinee will be unable to work in any position, or perform any range of work at JBS in the nominated industry
without exposure to workplace health and safety risk unless the following restrictions are observed:

Examiner Name

Examiner Signature: Date of Review:

Examiner
Qualification

REC05.2 Pre Employment Medical V10.2 20201130 13

Pre-Employment Medical Form

AUDIOMETRY TESTING (TO BE COMPLETED BY NURSE OR ACCREDITED SCREENER)

Surname Given Name(s)

Date of Birth Gender ☐ Male ☐ Female

JBS Site Date of Examination

CASE HISTORY

Pre Test Quite Ear Canals ☐ Normal ☐ Abnormal

Upper Respiratory Tract Infections ☐ No ☐ Yes _

Comments

At work do you wear ☐ Ear Plugs ☐ Ear Muffs ☐ Nil

PLEASE TICK YES OR NO Yes No

Do you consider the workplace noisy?

Have you EVER been involved in any of the following? Please tick all that apply.
☐ Army / Navy / Air Force ☐ Power Tools
☐ Gunfire or Explosives ☐ Noisy Hobbies

Have you EVER suffered from any of the following? Please tick all that apply.
☐ Ringing in the ears? ☐ Cold / Sinus?
☐ Ear Infections? ☐ Dizziness?
☐ Treatment / Surgery to ears? ☐ Head Injury?

Have you been in noise in the last 16 hours WITHOUT hearing protection?

Is there a history of HEARING LOSS in the family?

Do you have TROUBLE HEARING others in groups?

Do you wear a hearing aid?

Have you has a previous HEARING TEST?

I hereby given my employer access to the results of this hearing assessment and access to previous (
) hearing test results.

Applicant Signature: Date:

Further
Comments

REC05.2 Pre Employment Medical V10.2 20201130 14

Pre-Employment Medical Form

AUDIOMETRY TESTING (TO BE COMPLETED BY NURSE OR ACCREDITED SCREENER)

Surname Given Name(s)

Date of Birth Job Title

Nurse / First Aider Date

Accredited Screener Date

PURE TONE AUDIOGRAM

500 1000 1500 2000 3000 4000 6000 8000

10

20

30

Decibels (dB) 80

Right Ear
40 90

100

Left Ear
50

60
500 1000 1500 2000 3000 4000 6000 8000
70
Frequency in Hertz

HEARING LEVELS

Frequency Right Ear Left Ear Better Ear Worse Ear PLH

500

1000

1500

2000

3000

4000

REC05.2 Pre Employment Medical V10.2 20201130 15

Pre-Employment Medical Form

Overall Percent Loss of Hearing
Comments

REC05.2 Pre Employment Medical V10.2 20201130 16