Fit for Duty Declaration

Fit For Duty

Introduction

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 previous work or non- work related injuries, or medical conditions which may, or could potentially be, impacted by performing any of these above duties, you must disclose all such injuries or medical conditions below so that we can ensure we provide you with a safe working environment within your capabilities.

*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.

◻ I understand

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

Heavy lifting of objects up to 25 kg in weight,

Exposure to UV and other working / weather conditions for up to 12.5 hours (eg humidity, heat, cold, wind, rain and working in cold rooms),

Reaching overhead or above shoulder height,

Operating vehicles or machinery (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 in noisy work environments of up to 90 decibels,

Working in confined space,

Working at height,

Working with industrial chemicals

If you have any work or non- work related injuries or medical conditions* you must disclose all such injuries or medical conditions below 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.

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 Workers Compensation and Rehabilitation Act 2003 , for any event that aggravates the non- disclosed or falsely- disclosed pre- existing injury or condition, as per section 571.

Do you have difficulty with the following activities?

Question

Answer

Notes

Climbing a ladder

Crouching or kneeling

Shift Work

Working above shoulder height

Working in confined spaces

Working at heights

Bending and twisting

Walking on even ground

Sitting or standing for prolonged periods of greater than 2hours

Repetitive head or neck movements

Repetitive arm/wrist movements

Working in hot/cold conditions

Reading and writing comprehension

Do you speak any other language?

Do you or have you ever suffered from any of the following conditions?

Question

Answer

Notes

Back or neck problems

Cancer or tumour of any kind

Diabetes

Eye Trouble

Skin disorders/dermatitis

Hernia

Asthma/Bronchitis/lung problems?

Heart problems/chest pain/angina

High/low blood pressure

Any vascular or blood conditions. E.g. DVT, hepatitis

Fits/seizures/blackouts/persistent headaches

Head injury or concussion

Shoulder/Elbow problems

RSI/Carpal Tunnel/Overuse Syndrome

Foot/ankle/knee problems

Joint problems/fractures/arthritis/rheumatism

Loss of hearing/Ear infections/difficulty with conversation

Clinically diagnosed depression, anxiety or mental illness

Allergies or allergic reactions e.g. Dust, medications, food

Any other medical operation or conditions not previously listed. E.g. Kidney/liver/bladder/stomach disorders/ulcers/tropical diseases

Medical Status & History

Question

Answer

Notes

Please enter your height

Please enter your weight

Do you need to wear glasses for normal work?

Have you ever been hospitalised?

Have you ever had a Sporting injury?

Have you visited a chiropractor or physiotherapist in the last year?

Do you engage in regular exercise?

Do you or have you ever smoked?

Do you drink alcohol?

Do you or have you taken illicit drugs?

Do you have any issues taking an alcohol or drug test?

Is there any reason you are unable to wear personal protective equipment?

Have you ever been refused life or disability insurance, employment or military service?

Are you currently pregnant

Are you currently being treated by a doctor?

Are you taking medication/s?

Have you ever had a work related injury or illness

Have you ever claimed worker’s compensation?

Have you in the last five years had to have time off work for an injury or illness?

Confirmation

Please tick one of the following options:

I have pre-existing injuries or medical conditions and I have listed these injuries above. I have had a reasonable opportunity to provide this information. I confirm the medical information I have provided is true and not misleading.

◻I declare that I do not have any pre-existing injuries or medical conditions. I have had a reasonable opportunity to provide this information.

I require more time to allow a reasonable opportunity in order to consider that the information I am providing is true and not misleading.

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 Workers Compensation and Rehabilitation Act 2003 , 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.

◻ I agree

I do not agree

I am aware that if I am ultimately employed by the Company, I must inform the Company 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.

◻ I agree

I do not agree