SESLHD Pre-Employment Health Declaration Form

Employment with the South Eastern Sydney Local Health District (SESLHD) is conditional on the preferred applicant completing this statutory Pre-Employment Health Declaration form.

It is important that the SESLHD is made aware of any medical condition or other factors relating to your health and physical fitness so that the organisation can ensure safe systems of work and comply with its duty of care for all employees.

The pre-employment screening questionnaire relates to the applicant meeting the inherent requirements of the position under consideration, and enables SESLHD to ensure safe systems of work can be provided where pre-existing injuries and/or disease may be affected by employment with SESLHD.

Only staff immediately involved in the recruitment and selection process will have access to this information. A copy will be kept in a personnel file to assist with any emergencies, which may arise during the course of your employment with SESLHD or for the assessment of any claim for compensation to assist in the determination of liability.

The disclosure of information will not be used to discriminate against you because of the existence of any such disability or medical condition.

Position applied for
Position Reference Number
Given Name(s)
Family Name or Surname
If your name has changed please state your previous name(s)
Email address for all correspondence
Telephone No / Home……………………………………………………
Work…………………………………………………….
Mobile…………………………………………………..

Pre-Employment Health Screening Questionnaire

Have you read the position description and familiarised yourself with the inherent physical and psychological requirements of the role? Yes or No

Please answer each question by circling Yes or No

If YES please give details.

1
Are you currently being treated for any medical condition, illness, injury or disability (physical or psychological) that may affect your ability to safely perform the job that you have applied for (in line with the job demands checklist)? / YES
NO / If YES please give details
2
Have you ever had back, neck or other pain that persisted for more than a week? / YES
NO / If YES please give details
3
Have you ever made a claim for workers compensation in Australia or overseas? / YES
NO / If YES please give details
-Date of Injury:
-Employer at time of injury:
-Insurer:
-Nature of Injury:
  • If yes is the claim still open/current?
/ YES
NO / If YES please give details
-Current status of workers compensation claim:
-Current medical certificate restrictions:

Pre-Employment Health Screening Questionnaire

4
Have any of your previous contracts of employment been terminated on medical grounds? / YES
NO / If YES please give details
Date of termination –
Name of employer -
5
Are you returning to the workforce after an absence of more than 2 years? / YES
NO / If YES please give details
6
Does the position you have applied for involve significantly more physical components than your previous role/s? / YES
NO / If YES please give details
7
Are you limited in any way by a medical condition? / YES
NO / If YES please give details
8
Do you have hearing loss? / YES
NO / If YES please give details

Pre-Employment Health Screening Questionnaire

9
Do you suffer from dermatitis or any other skin problems / YES
NO / If YES please give details
Diagnosis:______
Are your hands and/or forearms affected? YES/NO
If Yes, do you require particular products to wash your hands and/or forearms? YES/NO
If Yes, please name the products: ______
10
Do you have an injury or underlying condition that may impact on your ability to carry out the position that you have applied for (in line with the job demands checklist)? / YES
NO / If YES please give details
11
Please specify any other condition not mentioned previously that may be aggravated whilst undertaking the inherent duties of this position. / YES
NO / If YES please give details
12. Please describe your level of comfort performing the following actions:
Activity / Difficult / Some Difficulty / No difficulty / Comments
Floor to waist level lifting 9kgs
Waist to eye level lifting 9kgs
Two handed carrying 9kgs
One handed carrying 5kgs
Pushing
Pulling
Prolonged sitting
Standing
Working with arms overhead
Working bent over - sitting
Squatting/crouching

Pre-Employment Health Screening Questionnaire

Activity / Difficult / Some Difficulty / No difficulty / Comments
Climbing stairs
Walking
Trunk rotation - standing
Trunk rotation - sitting
13. How would you best describe your general health on the following scale:
1 2 3 4 5 6 7 8 9 10
Poor Average Excellent

DECLARATION:

I declare that I have answered all of the above questions correctly and that I have not withheld any information regarding my past or present health.

I understand that a false declaration may result in any current or future contract of employment with SESLHD being terminated.

I understand that by signing this form I authorise South Eastern Sydney Local Health District (SESLHD) to release information to the pre-employment assessment team and in turn the pre-employment assessment team to release information to the SESLHD either verbal or written, in relation to the pre-employment assessment for which I may be referred.

If required, I am happy to provide any necessary information from my nominated treating doctor to support my application for this position.

I agree to have a functional capacity evaluation if requested

Name………………………………………………………..

Signature…………………………………………………….

Date………………………………………………………….

Certified by Convenor:

 The form has been reviewed and the required action taken as per Section 5.3 of SESLHD PR/370 Health Screening of Prospective Employees

Convenor Name………………………………………………….Date………………………………………

Convenor Signature……………………………Email……………………………@health.nsw.gov.au

Department/Ward…………………………….……….Facility/Service….………………………………

SESLHD District Form F286TRIM: T14/39243Date:March 20171 of 4