Celotti

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Employee Details & Pre-assignment Medical

Personal Details

* First Name

* Last Name

* Email

* Mobile

Phone

* Full Address

* Suburb

* State (Please use 3 letter format, EG NSW, VIC, WA etc)

* Postal Code

* Date of Birth

* Height (in cms)

* Weight (in kgs)

* Gender

Male

Female

Citizenship Status:

USI Number:

PPE Shirt Size:

* Do you identify yourself as being Aboriginal or Torres Strait Islander decent?

* Do you receive services from an employment services provider?

Yes

Employment Provider Name and Location:

Consultant Name and Telephone number:

Job Seeker ID Number:

Tickets/qualifications

* Drivers Licence/Proof of ID (Front)

Choose file

* Expiration Date

* Drivers Licence/Proof of ID (Back)

Choose file

* Expiration Date

White Card (Front)

Choose file

Expiration Date

White Card (Back)

Choose file

Expiration Date

* Birth Certificate/Passport

Choose file

Qualification - this may include trade papers, Machine tickets etc

Choose file

Expiration Date

Qualifications

Choose file

Expiration Date

Qualifications

Choose file

Expiration Date

QualificatioNs

Choose file

Expiration Date

QualificationS

Choose file

Expiration Date

QualificatioNS

Choose file

Expiration Date

QualificatiONS

Choose file

Expiration Date

Resume

Choose file

Emergency Contacts

* Emergency Contact Name

* Emergency Contact Phone

Relationship to you:

Address:

State:

Postcode:

General Health

Please answer YES or NO to answer the following questions. Note: if you answer “YES” to any question, you will be required to provide further information in the section provided or by a follow up phone call by a senior member of our team.

* DO YOU HAVE ANY MEDICAL CONDITIONS?

* ARE YOU CURRENTLY BEING TREATED BY ANY DOCTOR?

* DOES IT REQUIRE URGENT TREATMENT OR THE ADMINISTRATION OF MEDICATION?

* DO YOU HAVE ANY ISSUES WITH VISION I.E., WEAR GLASSES OR SIMILAR?

* DO YOU HAVE ANY ISSUES WITH HEARING I.E., WEAR HEARING AID?

* DO YOU HAVE ANY KNOWN ALLERGIES REQUIRING MEDICATION IF ENCOUNTERED (E.G., ADRENALIN, ANTIHISTAMINE?

* IN THE PAST FOUR WEEKS, HAVE YOU OR ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATION:

COLD AND FLU TABLETS OR SIMILAR (E.G., SUDAFED, COUGH MIXTURE)?

* IN THE PAST FOUR WEEKS, HAVE YOU OR ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATION:

Medicinal Cannabis, anti-anxiety medications, sleeping tablets or sedatives (e.g., Valium, Temazepam)?

IF YES TO ANY of the above, PLEASE PROVIDE DETAILS:

* DO YOU CURRENTLY SMOKE?

If YES, how long have you smoked (months or years)

* DO YOU DRINK ALCOHOL?

If YES, how many standard drinks would you have per week?

* ARE YOU CURRENTLY TAKING ANY NON-PRESCRIBED SUBSTANCES?

If YES, please provide details

Physical Health

* Neck discomfort or pain?

* Fractures (broken bones)

* Shoulder pain, tendonitis, frozen shoulder

* Epicondylitis (Tennis Elbow or Golfer’s Elbow)

* Arthritis, joint pain or swelling with: Any joints of upper limb (shoulder to elbow) Arm (elbow to wrist) and / or. Hand (including fingers)

* Wrist pain, ganglions, Carpal Tunnel Syndrome (medically diagnosed) or Repetitive Strain Injury or pain with upper limb (shoulder to elbow), arm (elbow to wrist) and/or hand (including fingers)

* Numbness with and and/or fingers

* Issues with any part of the middle or lower back

* Issues with hip/hips

* Sciatica or leg pain

* Knee injury, swelling and/or pain (including surgery/arthroscopy)

* Ankle and/or feet pain/problems with walking and/or standing

* Skin issues e.g., dermatitis, eczema, psoriasis etc.

* Hernia (abdominal and/or inguinal)

* Heart attack, Angina or Cardiac Pacemaker?

* Hypertension (High blood pressure) or Hypotension (low blood pressure)

* Stroke

If YES to any, please provide details:

Have you experienced or currently experience issues with any of the following

* Head injury/s (e.g., concussion, brain trauma), regular headaches/migraines, seizures, co-ordination, unconsciousness, or other neurological experiences?

Yes

* Have you ever been diagnosed with a Mental Health condition/illness?

Yes

If YES to the previous questions, please provide further details below:

* Have you experienced or currently experience issues with any of the following?

If YES to the previous questions, please provide further details below:

Occupational Health

* HAD A WORK-RELATED INJURY OR ILLNESS IN THE LAST FIVE (5) YEARS?

* UNDERTAKEN A REHABILITATION PROGRAM FOR ANY WORK-RELATED INJURY?

* IN THE LAST FIVE (5) YEARS HAD TIME OFF BECAUSE OF A WORK-RELATED INJURY OR ILLNESS?

* EVER LODGED A WORKER’S COMPENSATION CLAIM?

If previous injury, has the final clearance medical been provided?

* EVER WORKED WITH ANY SUBSTANCES OR IN ANY CONDITION/S THAT MAY HAVE BEEN HAZARDOUS TO YOUR HEALTH? E.G., ASBESTOS, TOXIC CHEMICAL EXPOSURE E.G., LEAD, CONCRETE/SILICA, NOISY ENVIRONMENTS ETC.)?

* EVER UNDERGONE BLOOD SCREENING/DIAGNOSTICS FOR SUBSTANCE EXPOSURE AT WORK?

* EVER RETURNED A POSITIVE DRUGS & ALCOHOL TEST WITHIN THE LAST 12 MONTHS?

* BEEN EXPOSED TO PROLONGED USE AND/OR USE OF HEAVY TOOLS E.G., JACKHAMMER, SLEDGEHAMMERS.

If YES to any of the previous questions, please provide further details below:

* Do you have any difficulty with wearing standard safety/personal protective equipment (e.g., safety shoes or boots, helmets etc)?

Yes

If you answered yes above, please specify which piece of PPE equipment and how you use alternatives?

* Do you have any difficulty? (Please select from the below, use N/A if none apply)

If YES to any of the previous questions, please provide further details below:

* Do you have any difficulty with repetitive movements involving any body part? E.g., Shoulders, Wrists, elbows?

Yes

If YES, please provide further details below:

* Do you have any difficulty with any of the following? (Please select from the below, use N/A if none apply)

If YES to any of the above questions, please provide further details below

Reference Check

* Reference Name 1

* Reference Company 1

* Reference Phone Number 1

* Reference Name 2

* Reference Company 2

* Reference Phone Number 2

Employee Declarations

* I agree that all the above details I have provided are truthful and accurate with no omissions or misleading answers. I acknowledge that by failing to disclose any relevant information about any pre-existing injuries or medical conditions could put me at serious risk and result in me not being entitled to compensation or to seek damages for any event that aggravates the pre-existing injury or medical condition