Fitness For Work Declaration

PURPOSE: WARGL is committed to establishing and maintaining a safe and fair work environment for all workplace participants. Collecting medical information about workplace participants has three purposes:

Name*

First Last

Email*

Medical History Part 1 - Have you ever received treatment or medical advice for any of the following:*

Medical History Part 1 - Please provide further detail below*

Medical History Part 2 - Have you ever received treatment or medical advice for any of the following:*

Medical History Part 2 - Please provide further detail below*

Part 3 -Do you have any difficulty with any of the following activities?*

Climbing a ladder
Using hand tools
Lifting or bending
Gripping firmly with both hands
Reading ordinary print
Repetitive movement of hands and arms
Crouching
Understanding English
NONE OF THE ABOVE

Part 3 - Please provide further detail below*

Height (cm)*

Various Plant and Equipment you may be required to operate have seat weight ratings. We also work in remote locations where emergency evacuation procedures stipulate weight restrictions.

Weight (kg)*

Various Plant and Equipment you may be required to operate have seat weight ratings. We also work in remote locations where emergency evacuation procedures stipulate weight restrictions.

IMPORTANT NOTICE - WORKERS COMPENSATION*

I solemnly declare that each and every answer above is true to the best of my knowledge and belief. I understand that any false or misleading information may result in termination of employment. I understand that I may also be required to undergo a hearing test on termination of employment.

Agree and declare
Opt Out

“Section 79 of the workers compensation and injury management act (1981) gives the workers compensation board discretion to refuse to award compensation, which would otherwise be payable, where it is proved that the worker has, at the time of seeking or entering employment, wilfully and falsely represented him/herself as not having previously suffered from the disability, the subject of the claim for workers compensation.”