Pre-engagement Health Declaration

Whizdom is committed to protecting the health, safety and wellbeing of all its employees and contractors. Whizdom strives to ensure that people do not undertake work for which they are not suited and to take appropriate measures to allow work to be done in a manner which will not put them or any other person at risk.

In order for Whizdom to protect your health, safety and wellbeing, we request that you advise us of any previous, pre-existing injuries or health conditions that you are aware of.

This Pre-employment Health Declaration form will assist Whizdom in:

determining if the prospective contractor would be able to safely carry out the inherent requirements of the role
determining what reasonable adjustments could be made for the contractor to mitigate the risk of them sustaining further injury in the role
ensuring the workplace health and safety of the contractor and/or their co-workers

Whizdom can work with you and the host client, where applicable, to arrange reasonable adjustments where you have a pre-existing injury, illness and/or condition, including consideration to reasonable modifications to the environment.

All information received regarding pre-existing injuries and medical conditions are strictly confidential and is in keeping with Whizdom’s Privacy Policy and Collection Notice

First Name

Last Name

Are you aware of any circumstances regarding your health or capacity to work which may impact your ability to perform the duties of the position? *

YesNo

In answering this question Yes or No you are also covering factors such as: existing or exposure to infectious diseases, taking of medication/treatment on a regular basis (daily, weekly, monthly). If yes, what adjustments do you need to perform the inherent requirements of the position (if any)?”

Question 1 detailsIf yes, please provide details

Do you have an existing injury or medical condition or pre-existing injury or medical condition that could be affected by the nature of the proposed employment?

YesNo

Existing is a medical condition for which treatment is still being received. Pre-existing is where an injury or medical condition/s is present, but treatment is not required. If yes, please provide details of the injury or medical condition(s). If yes, what workplace adjustments do you need to perform the inherent requirements of the position (if any)?”

Question 2 detailsIf yes, please provide details

Have you ever worked with any substances or in any conditions which may have been hazardous to your health (e.g. asbestos exposure, toxic chemicals, stressful or noisy environments) and may impact your ability to perform the duties of the position and for which you need a modified workplace?

YesNo

Question 3 detailsIf yes, please provide details

Do you have a current or any previously accepted Workers Compensation Claims?

YesNo

Question 4 detailsIf yes, please provide details

Are you required to take medication which may impact on your ability to perform the duties of the position?

YesNo

Question 5 detailsIf yes, please provide details

Are there any other workplace adjustments or modifications that you require to perform the inherent requirements of your position?

YesNo

Question 6 detailsIf yes, please provide details

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