EMPLOYEE HEALTH

DECLARATION

As your employer, EMERY H.R. Business Support Pty Ltd, is responsible for your health, safety and welfare
whilst at work. Therefore, it is important that we are aware of any condition, medical or otherwise,
which may have an impact on you in the workplace. This Questionnaire is not designed as a tool to
discriminate, rather to create awareness and ensure you are properly accommodated in the workplace.

Name: ......................................................................................................................
Daytime Telephone: ......................................................................................................................
Please nominate the type of duties and employment you are applying for ie. Clerical, data entry:
……………………………………………………………………………………………………………………………………………………………..…
………………………………………………………………………………………………………………………………………………………………..

YES NO If yes, please comment

 From a Doctor
 From a physiotherapist
 From a chiropractor
 Other health practitioner (ie Herbalist, Acupuncturist etc).
Have you:
 Had any medical treatment in the last 6 months?
 A current workers compensation claim?
 Had a workers compensation claim in the last 2 years?
 Been off work for longer than 1 month for an injury,
accident or illness?
 Ever been in hospital?
 Ever had an operation?
 Had a ‘medical’ in the last 6 months and been refused
employment?
 Any medical condition you feel is relevant to your
suitability for the type of work you are applying for?
Have you ever had or currently have:
 Heart disease or heart attack
 High or low blood pressure
 Asthma or other respiratory illnesses
 Chronic bronchitis or emphysema
 Fits or epilepsy
 Depression/Anxiety or other mental illness
 Neck/back pain, slipped disc or back surgery
 Arthritis, soreness or injury to any joints or muscles
 YES NO If yes, please comment.
 Dermatitis, eczema, skin irritations
 Diabetes
 Dizzy or fainting attacks
 Sleep related disorder
 Medications (antihistamines, painkillers, sedatives)
 Unusual muscle weakness
 Have you had any allergy from or related to any
antibiotics, medicine, drugs, insect bites, food or anything
else
Do you:
 Take medicines, mixtures or tablets at present
 Have any medical condition(s) that you feel should be
noted
 Have any medical condition(s) that would be identified at
a medical conducted by a Doctor
 Do you wear prescription glasses or contact lenses
Physical Abilities, can you:
 Travel in small planes
 Work in confined spaces or at heights
 Run 100 metres
 Climb a ladder
 Walk over rough ground
 Crouch and kneel
 Lift 10kg without trouble
 Use hand tools
 Wear a respirator (protective equipment)
 Wear protective spectacles
 Wear a safety hard hat
 Wear steel capped lace up safety boots
 Do you have any restrictions that would stop you from
doing your job adequately?
 Sit or Stand for long periods
 Operate a keyboard for long periods (with adequate
breaks)
Other information:
 Do you have good peripheral (side) vision from both eyes
 Do you have normal hearing in both ears
 Do you drink alcohol
If yes, please list standard drinks per week

 Would you accept a temporary employment placement in

What is the general state of your health? Please elaborate on any medical conditions we need to be aware of:

…………………………………………………………………………………………………………………………………………………………………………………………………...
…………………………………………………………………………………………………………………………………………………………………………………………………...
…………………………………………………………………………………………………………………………………………………………………………………………………...
…………………………………………………………………………………………………………………………………………………………………………………………………...
…………………………………………………………………………………………………………………………………………………………………………………………………...
…………………………………………………………………………………………………………………………………………………………………………………………………...
WORKER'S COMPENSATION (Please circle the appropriate response)
Do you have any pending Workers Compensation or any disability claims whatsoever? Yes No

If yes to the above question, please specify details of the claim made and the expected timeframe for an
outcome:

Approximate Date Name of Employer Nature of the claim Duration

_________________ _______________________ _____________________ __________

_________________ _______________________ _____________________ __________

 I certify that all information provided by me is at the time of completion true and correct to the
best of my knowledge. Should any factors relating to my health and well-being change at any
time in the future, whilst in the employment of EMERY H.R. Business Support Pty Ltd, it’s clients
or associated entities, I agree to inform all relevant parties immediately and understand this
may impact on the duties I am able to perform in my employment.

 I understand that failure to disclose any medical conditions or injuries may result in dismissal
from my temporary assignment.

 I also agree to report any incidents or injuries which occur in the workplace, immediately to the
supervisor at my host employer and to EMERY H.R. Business Support Pty Ltd, as required by
legislation.

Signature: _________________________________________________

Print Name: _________________________________________________

Date: __________________________________________________

If you have any questions or concerns relating to this Declaration, please contact Kathryn Blackmore –
Manager of EMERY H.R. Business Support Pty Ltd; on 4933 4100.