Candidate Registration Form

As a labour hire company, the roles and workplaces we may offer you if you are ultimately employed by us can frequently vary. To ensure that we can provide you and our employees with a safe working environment, we will require you to complete the following fit for duty declaration form.

If you have any work or non-work-related injuries or medical conditions you must disclose all such injuries or medical conditions so that we can ensure we provide you with a safe working environment within your capabilities. The Company may also require you to provide medical certificates or undergo medical assessments to ensure that you are physically fit to perform the role.

For the purposes of this document, injuries or medical conditions means an injury or medical condition existing at the time of this declaration that you suspect or, ought reasonably to suspect, would be aggravated by performing the duties listed in this document.

Some duties you may be required to perform in the workplace if you are ultimately employed by us may include, but are not limited to:

• Heavy lifting of objects.
• Reaching overhead or above shoulder height,
• Operating medical machinery/equipment (if skilled/licenced to operate). This requires excellent hand/foot/eye coordination and visual abilities such as distance vision, colour vision peripheral vision, depth perception and ability to adjust focus,
• Prolonged standing or sitting both indoors and outdoors,
• Walking on uneven and/or inclined surfaces, and up and down stairs,
• Regular bending / twisting / squatting / crouching movements,
• Regular pushing / pulling / gripping movements,
• Tasks which may be repetitive in nature,
• Working with chemicals
• Management of infectious disease and infection control

Please note that if you provide false or misleading information, or if you do not disclose any injuries or medical conditions which may, or could potentially, impact your ability to perform these tasks, you will not be entitled to compensation or damages under the relevant state and/or federal legislation, for any event that aggravates the non-disclosed or falsely-disclosed pre-existing injury or condition.

Please refer to PeopleIn’s Australian Privacy Principles (APP) privacy policy for information on:

(a) how you can access and correct the health information PeopleIn hold about you.

(b) how you can make a complaint about how PeopleIn handles your health information, and details of how PeopleIn will deal with a complaint.

(c) the parties to whom PeopleIn may, with your consent, disclose your health information.

Personal Information

Address

Emergency Contact

Job Network

Criminal History Declaration

Medical Questionnaire

Please answer the following questions regarding your current medical status and history:

Due to the physical nature of the job and the lifting / manual handling required, please let us know if you have any difficulty with the following activities:

Given the written and verbal communication skills necessary to undertake the job, please let us know whether you have any difficulties with:

Do you or have you ever suffered from any condition/injury to; If yes, please provide details including diagnosis, date of injury, have you fully recovered, do you have any ongoing physical limitations?

Do you or have you ever suffered from the following; If yes, please provide further details including diagnosis & date you first suffered the condition, if there is anything we need to be aware of that may limit you to perform your tasks or if there are any necessary workplace supports we can implement? (ie. triggers that could exacerbate your condition, workplace environment, extra supports etc.)

Medications

Workers Compensation

Vaccinations

Some employees depending on their job classification may be put at risk for exposure to bloodborne pathogens or viruses. As such please let us know if you have been vaccinated against the following?

Declaration

1. I consent to Edmen Community Staffing Solutions to hold my sensitive information for the purpose of my job application and any ongoing placement or employment opportunities.
2. I consent to my past employers and the relevant authorities being contacted to confirm details of my employment history, qualifications and licences detailed in this application, and Australian Work Right Status.
3. I authorise the WorkCover Claims Branch to supply a record of my claims history (if any).
4. By submitting this completed medical questionnaire to the company electronically I confirm that I completed this medical questionnaire accurately and honestly. I understand that if, after completing and submitting this medical questionnaire, the company becomes aware that I have not been completely truthful in answering this medical questionnaire the company has the right to take disciplinary action against me including the termination of my employment.
5. I am aware that if I am employed by Edmen, I must inform Edmen immediately regarding any injury or medical condition (work and non-work related) that I sustain throughout my employment, to ensure that I am not placed at risk of aggravating this injury or medical condition whilst performing my work duties.
6. I have read and understand the statement outlined above. I have had a reasonable opportunity to comply and provide this information. The information I have provided is true and not misleading and I acknowledge that if an aggravation occurs to an injury or medical condition which I have not disclosed, or in which I have provided false information, this will not be compensable under the relevant state/and or Federal legislation, and I will be unable to seek damages for any event that aggravates the non- disclosed or falsely- disclosed pre-existing injury or medical condition.