| Checklist | Yes | No | |||||||
| 1. Are you currently engaged in any other employment, which will continue if you are successful in gaining this position? | |||||||||
| 2. Have you ever been diagnosed with and/or treated for Occupational Overuse Syndrome or any other similar condition? | |||||||||
| 3. Do you, or have you ever suffered from any back problems? | |||||||||
| 4. Do you think the back problem will cause you any limitations in the type of employment you are seeking? | |||||||||
| 5. Do you, or have you ever suffered from any form of hearing problem? | |||||||||
| 6. Do you, or have you ever suffered from any eyesight impairment, including needing to wear glasses? | |||||||||
| 7. Have you received any injury that has resulted in you being on ACC support within the last five years? | |||||||||
| 8. Do you have any other condition that you are aware of, including but not limited to asthma, diabetes, epilepsy, allergies, heart or respiratory problems or high blood pressure? | |||||||||
| Comments (If you answered Yes to any of the above questions, please add comments in corresponding box) |
| Employment type and hours: |
| 1. When: Employment Type: Completion Date: |
| 2. When: Treatment Type: Completion Date: |
| 3. How? |
| 4. Treatment Type: Severity: |
| 5. Treatment Type: Severity: |
| 6. Treatment Type: Severity: |
| 7. Treatment Type: Severity: |
| 9. Injury: Treatment Type: When: |
| 10. When Treatment Type: Completion Date: |
| Name: | Date: |
| Position applied for: | Signature: |
The information above has been provided by myself, voluntarily.
NOTE: As a precondition of employment, you may be required to undergo a medical examination.
NOTE: Failing to answer medical questions in relation to work related gradual process injuries accurately may result in a disentitlement to any cover for those injuries, under the Act. Deafness or hearing loss under the Act may not be covered for work related injuries if the employee has not undergone a baseline hearing test, before commencing employment