Schlam Engineering

Fitness For Work and Medication Declaration

Applicant Details

* First Name

* Last Name

* Email

* Mobile

* Date of Birth

* Street

* City

* State

* Postal Code

* Country

* Position applied for

* Date

Fitness For Work

Schlam Cru is committed to ensuring the health and safety of its employees. To ensure you are fit to safely perform the inherent requirements of the position you are applying for, Schlam Cru requires you to complete this Fitness for Work form.

What your information is used for

Once you have completed this form, Schlam Cru will review the information you have provided together with any pre-employment medical reports regarding your fitness to perform the inherent requirements of the position. Schlam Cru will use this information to determine whether you are fit to perform the inherent requirements of the position.

If you do not complete and return a copy of this form to Schlam Cru, Schlam Cru will be unable to determine if you are fit to perform the inherent requirements of the position and due to work health and safety requirements, will not be able to proceed with your application.

Privacy

By completing this form, you consent to Schlam Cru being provided with the personal information that is contained in it. If you are offered employment with Schlam Cru, this form and the information you provide in it will be securely stored as part of your employee file with Schlam Cru. If you are unsuccessful in your application, Schlam Cru will retain this form and the information you have provided on your candidate file for 30 days, after which the information will be destroyed. More information about how Schlam Cru handles your personal information is available in our Privacy Policy or you can contact us directly with your query.

Medical Details

* Are you aware of any medical condition, injury or illness that may impact your ability to perform the inherent requirements of this position with Schlam Cru?

Yes

(1) If Yes, please provide details:

* Are you currently receiving ongoing treatment or participating in ongoing management of any injury or medical condition?

Yes

(2) If Yes, please provide details:

* Do you have any existing condition or injury that may be affected or aggravated by the nature of this position?

Yes

(3) If Yes, please provide details:

* If you have any existing condition, injury or illness, will you require any modifications to the workplace or the equipment you use in order to assist you to safely perform the duties of the position?

Yes

(4) If Yes, please provide details:

* Are you currently taking any prescription medication, or other medication (including over the counter medication and vitamins), that may impact your ability to perform the inherent requirements of the position?

Yes

(5) If Yes, please specify the medications:

* Is there any reason you will not be able to wear personal protective equipment?

Yes

(6) If Yes, please provide details:

* Do you have any allergies that you may come into contact with, in the workplace, (e.g. food, medication, environmental allergies)?

Yes

(7) If Yes, please specify the allergy and the treatment you require in event of exposure:

* Are there any other circumstances you are aware of that you have not disclosed in this form that may affect your ability to perform the inherent requirements of the position?

Yes

(8) If Yes, please provide details:

Declaration

* I declare that the information provided in this form is true and correct to the best of my knowledge and that I have not withheld any information regarding my current or past health.

I understand that providing false information may result in Schlam Cru withdrawing any offer of employment to me or disciplinary action, including termination of employment.

Medication Declaration

Schlam Cru requires all workers to be fit for work when they present at the workplace.

All workers are required to declare any medication they are consuming that may affect their fitness to work safely or that may show up on a drug screening test (including medication containing codeine). Medication must be declared by completing this form and submitting it to your supervisor or manager as soon as practicable after taking medication and before attending your next shift. If your medication changes during your employment, you must declare the new medication to Schlam Cru before your next shift following the change.

If you are taking prescription medication that may affect your fitness for work, you must submit (with this form) a copy of your prescription and a letter from your doctor that confirms you are fit for work while taking the medication or states how your fitness for work is impacted and the likely duration you will be required to take the medication.

If you are unsure if your medication may impact your fitness to perform work safely, you should speak with your doctor. Some examples of medications that could affect your fitness for work include strong pain killers, medication containing codeine, sleeping tablets, medicinal cannabis, dexamphetamine and Duromine.

Schlam Cru will securely store your completed Medication Declaration form on your employee file during your employment.

Medication(s)

(1) Name of Medication

(1) Nature of medication (i.e. prescription or over the counter)

(1) Duration of mediation

(1) Are you experiencing any side effects? (if yes, please provide details)

(2) Name of Medication

(2) Nature of medication (i.e. prescription or over the counter), (2) Duration of mediation

(2) Duration of mediation

(2) Are you experiencing any side effects? (if yes, please provide details)

(3) Name of Medication

(3) Nature of medication (i.e. prescription or over the counter)

(3) Duration of mediation

(3) Are you experiencing any side effects? (if yes, please provide details)

Declaration

* I declare that I am taking the medication specified in this form, as prescribed by my doctor, or in accordance with the instructions provided to me for over-the-counter medication. I confirm all information contained in this form is true and correct to the best of my knowledge and understand that Schlam Cru will rely on this information to ensure I am fit to work.