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Declaration of Work Fitness

Do you suffer from any injury, ailment or condition which may adversely affect your work performance, regular attendance at work, or adversely affect the health and safety of others, or which we should be aware of in order to provide assistance should the
Yes
No
Are you currently receiving medical treatment or under medication, or suffer a condition which we should be aware of in order to provide appropriate assistance should the need arise?
Yes
No
Do you suffer from, or have suffered, any injury, problem or condition which could be attributable to gradual process, occupational overuse syndrome or RSI?
Yes
No
Did you or do you suffer from, or have suffered, any injury, problem or condition from your previous employment?
Yes
No
Given the physical tasks associated with your prospective employment, do you suffer from, or have you suffered any injury or problem in respect of your:
Do you suffer from, or have suffered any condition which may be affected by our work process, services, and work environment, such as:
Should your application for employment be successful, do you agree to attend a Registered Health Professional nominated by the employer to undertake such consultation, examination or tests as may be appropriately required?
Yes
No

DECLARATION:

I have personally completed this questionnaire, and the information I have provided is an accurate and honest declaration.

I understand that should I be successful in my application for employment, falsification or deliberately misleading information, or material suppression or information will be treated as serious misconduct for which the penalty is instant dismissal.

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