Professional Questionnaire

Step 1 of 4

25%

Candidate Details

Full Name

Employee ID

Email Address

Phone Number

Address

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.

Yes

Enter Full Name

(If Yes) Please provide details

Are you subject to any pending charges before any Court? If yes to any pending charges before any Court, then please explain:

Yes

(If Yes) Please provide details

Do you have a current Police Clearance?

Yes

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

Yes

Asthma

Yes

Blood Pressure/Heart problems/Circulatory issues

Yes

Disorders

Yes

Anxiety/Depression

Yes

Fits/Seizures/Blackouts

Yes

Stomach Problems/Ulcers

Yes

Repetitive Strain/Overuse conditions

Yes

Arthritis/Rheumatism

Yes

Joint Pain or Fractures

Yes

Back or Neckpain/discomfort/stiffness

Yes

Loss of Hearing

Yes

Visual (eyesight) impairment

Yes

Diabetes

Yes

Skin Disorders/Dermatitus

Yes

Have you ever had any surgery? If yes to any surgery in the past, please explain

Yes

(If Yes) Please provide details

Do you or have you ever smoked?

Yes

(If Yes) Please provide details

Do you undertake regular exercise?

Yes

Do you drink alcohol?

Yes

If yes how many drinks per week?

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

Lifting more than 20 kg

Yes

Rotation of your head from side to side

Yes

Gripping firmly with both hands

Yes

Repetitive movement of the hands/arms

Yes

Shift work

Yes

Reading ordinary newsprint

Yes

Understanding written English

Yes

Understanding verbal English

Yes

Hearing in a normal conversation

Yes

Have you ever had a workers’ compensation claim? If yes to the workers’ compensation claim, please explain.

Yes

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”

If YES, please provide specific details of employer, dates of injury, insurer and nature of claim/Injury

Professional Manual

The below manual will provide you with training in Flexi Staff safety processes and generic hazards, and assist you throughout the following questionnaire.

Download the Professional Manual

Module One: Duty of Care

1. Occupational Safety and Health is the responsibility of ________________ to ensure, so far as practicable, a safe working environment.

Host employer

Flexi Staff management

Employees

All of the above

2. As an employee of Flexi Staff Pty Ltd you have a duty of care for your __________ and of ________ affected by your actions at work.

‘Safety and Health’ and ‘others’

‘Plant’ and of ‘Equipment’

‘Supervisor’ and of ‘Host Employer’

Module Two: Fitness for Work

3. Whilst onsite you notice a Flexi Staff employee acting in a manner which could be the effect of drugs or alcohol, you should ____________.

Ignore him/her

Inform your Supervisor

Tell him/her to go home

Give them a cup of coffee

4. Flexi Staff employees have a responsibility to present for work or remain at work in a condition in which they are fit to carry out normal duties.

True

False

5. Fatigue has the capability to affect one’s ability to identify hazards.

True

False

6. Fatigue can be caused by which of the following:

Demanding shift rosters

Personal/home issues

Drugs and alcohol

All of the above

7. Alcohol diminishes which of the following:

Environmental awareness

Cognitive function and physical activity

Response to sensory stimulation

All of the above

8. When may you be subjected to a drug and alcohol test:

Pre – placement testing

Random testing

For cause testing

All of the above

Module Three: Incident Management

9. The Incident Management and Investigation procedure ensures all ________________ , including near hit incidents are managed in a standardised manner.

Accidents

Mishaps

Incidents

Injuries

10. You must _____________ report any _______________ to your Supervisor and your Flexi Staff office

‘Sometimes’ report any ‘incidents’

“Immediately’ report any ‘incident, accident or injury’

‘Never’ report any ‘Incidents’

11. When an incident occurs you must immediately _________ the scene/area to prevent further injury or __________.

Secure and harm

Leave and harm

Clear and damage

Module Four: Hazard Management

12. The first step in managing hazards is:

Hazard Identification

Purchasing equipment

Risk Control

13. The second step in managing hazards is:

Risk Control

Imposing procedures

Risk Assessment

14. The third step in managing hazards is:

Consulting workers

Risk Control

The Safety Committee

15. As an employee, your responsibility in the four step Hazard Management process is to:

Control risks

Assess risks

Identify and report hazards

Module Five: Workplace Hazards

16. ____________ can be defined as any task that involves lifting, carrying, pushing, pulling or holding.

Work

Manual Handling

Manual dexterity

Movement

17. An effective method to reduce manual handling injuries is to ___________.

Use lifting and moving equipment

Adjust working height

Maintain a good posture

All of the above

18. Any movement that twists, or bends the torso should be _____________.

Avoided wherever possible

Done quickly

Practiced

Encouraged

19. Wearing the correct footwear to work can reduce your risk of slipping, tripping and falling.

True

False

20. Electric shocks can be caused by:

Failing to isolate electricity correctly

Damaged/exposed electrical leads

Faulty electrical equipment

All of the above

21. If I am worried about the electrical safety of the tools I am using I should:

Continue working and note any sparks

Report the fault to my colleague

Report the fault to my supervisor and tag out of service

Module Six: Professionals Specific Workplace Hazards

22. Muscle strain and fatigue when working in an office environment can be minimised by adopting a “good posture”.

True

False

23. Good posture means that:

Your shoulders are relaxed

Your elbows are level with the side of your body

You maintain a balanced, upright head position

All of the above

24. Workstations do not need to be adjusted for individual users.

True

False

Module Six: Emergency Procedures

25. Whenever you commence at a new placement, you should:

Start work immediately; to give a good impression

Participate in an onsite induction, including emergency procedures

Go to the nearest emergency exit and test fire extinguishers yourself

Module Eeven: Code of Conduct

26. Bullying can be defined as: A __________, directed towards a person or group of persons in the workplace, tahat is _________, unreasonable or inappropriate and that creates a ______to health and ________.

'Action' and 'Unwelcome' and 'Harm' and 'Safety'

'Behaviour' and 'Repeated' and 'Risk' and 'Safety'

'Comment' and 'Rude' and 'Problem' and 'wellbeing'

27. Who can I contact if I believe I am being bullied?

Manger/Supervisor

Flexi Staff Representative

Fairwork Commission

All of the above