Industrial Questionnaire

Industrial Questionnaire

Step 1 of 5

Candidate Details

Criminal History

Do you have any current convictions for any offenses from any Court? If yes to current convictions for any offenses from any Court, then please explain. If no to current convictions then please enter your Full Name in the box provided.
Are you subject to any pending charges before any Court? If yes to any pending charges before any Court, then please explain:
Do you have a current Police Clearance?

Medical Questionnaire

Please complete all questions in the following Medical Questionnaire. For any question that you answer “YES” please provide details.

Section (79) of the Western Australian Workers Compensation and Injury Management Act 1981 requires you to disclose any prior illness or injury otherwise you may not be entitled to compensation in the event of illness or injury.

Wilful and false representation
Where it is proved that the worker has, at the time of seeking or entering employment in respect of which he claims compensation for an injury , wilfully and falsely represented himself as not having previously suffered from the injury an arbitrator may in the arbitrators discretion refuse to award compensation with otherwise would be payable”

[Section 79 amended by No. 48 of 1993 s. 28(1); No. 42 of 2004s. 63, 146 and 147.]

     
Please indicate if you have ever suffered from the following:
Lung Problems/Bronchitis
Asthma
Blood Pressure/Heart problems/Circulatory issues
Disorders
Anxiety/Depression
Fits/Seizures/Blackouts
Stomach Problems/Ulcers
Repetitive Strain/Overuse conditions
Arthritis/Rheumatism
Joint Pain or Fractures
Back or Neckpain/discomfort/stiffness
Loss of Hearing
Visual (eyesight) impairment
Diabetes
Skin Disorders/Dermatitus
Have you ever had any surgery? If yes to any surgery in the past, please explain
Do you or have you ever smoked?
Do you undertake regular exercise?
Do you drink alcohol?

Physical abilities: Do you have, or have you ever had difficulty with any of the following:

Hot/Cold Conditions
Working at heights
Lifting more than 20 kg
Rotation of your head from side to side
Gripping firmly with both hands
Using vibrating hand tools
Repetitive movement of the hands/arms
Shift work
Confined spaces
Reading ordinary newsprint
Understanding written English
Understanding verbal English
Bending repetitively
Hearing in a normal conversation
Kneeling
Sitting constantly for 2 hours
Standing constantly for 2 hours
Wearing Personal Protective Equipment
Please select all that apply
Have you ever had a workers’ compensation claim? If yes to the workers’ compensation claim, please explain.
     

Please read the extract from the Workers’ Compensation and Rehabilitation Act 1981 Section (79) prior to completing this Workers Compensation declaration:

“Where it is proved that the worker has, at the time of seeking or entering employment in respect of which he claims compensation for a disability, wilfully and falsely represented himself as not having previously suffered from a disability a dispute resolution body may at its direction refuse to award compensation which otherwise would be payable”

Get in touch with us:
Belmont 08 9479 4781
Rockingham 08 9592 7500