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Pre-Employment Medical Exam

Home > Employment > Protected: Employment Forms > Pre-Employment Medical Exam

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Pre-Employment Medical Examination

Pre-Employment Medical Examination
Name

First

Last
Address

Address line 1

Address line 2

Town/suburb

State

Postcode

Country
Date of Birth

Day

Month

Year
Sex
- Male
- Female
Prospective employees of the Midfield group of companies are required to complete the following health history questionnaire. The nature of employment at Midfield involves many varied tasks that may involve heavy manual work.
This completed questionnaire will be provided to the doctor and/or physiotherapist who will assess your medical status to carry out the tasks required. This procedure is necessary to protect both yourself and the company and to ensure your health is not put at risk by you accepting any job that the company may offer. Your continued good health whilst you are employed by Midfield will be important to you, your family and the company.

Your Legal Obligation

You are required to disclose any pre-existing injuries and/or diseases that you have which could be affected by the nature of your proposed employment at Midfield.

If you fail to disclose any pre-existing injuries and/or diseases, or make a false or misleading disclosure, any recurrence, aggravation, acceleration, exacerbation or deterioration of the pre-existing injury or disease arising out of or in the course of or due to the nature of your employment with Midfield, you will not be entitled to compensation under workers’ compensation legislation.

The position you have applied for may involve the following requirements:
- Repetitive Bending
- Twisting
- Checking product
- Standing
- Shift work
- Sweeping
- Working in cold environments
- Lifting
- Working in moist environments
- Driving
- Hosing
- Cutting (with knives or other sharp implements)
- Maintenance of machinery
- Wearing of boots, overalls, apron and protective clothing
- Contact with animals
- Being able to perform all of these requirements in a safe
  manner without risk to the health and safety of yourself,
  other employees and third parties.
In light of your legal obligations outlined above, do you have any pre-existing injury or disease related to the following parts of the body?
Please select those that apply.
- Back
- Wrists
- Shoulders
- Elbows
- Knees
- Ankles
If yes, please provide details:
In light of your legal obligations outlined above, do you have any of the following pre-existing injuries?
Please select those that apply.
- An overuse injury
- Repetitive strain injury
- Carpal Tunnel
If yes, please provide details:
In light of your legal obligations outlined above, do you have any other pre-existing injury or disease you wish to disclose?
Please provide details.
Do you have, or have you had, any injury, disease, illness, disability or health ailment which may affect your ability to fulfil the requirements above in a safe manner?
For example, a person who suffers from blackouts or fainting may not be able to cut safely with knives.
- YES
- NO
If YES, please provide details
Do you have, or have you had, any injury, disease, illness, disability or health ailment which may affect your ability to respond adequately to an emergency?
For example, a person with a hearing impairment may not be able to hear a warning.
- YES
- NO
If YES, please provide details
Are you taking nay medication (prescription or otherwise) which may affect your ability to fulfil the requirements above in a safe manner?
For example, some medications may cause sleepiness or drowsiness which may affect a person's ability to operate machinery or drive a vehicle or use knives safely.
- YES
- NO
If YES, please provide details
Are you taking nay medication (prescription or otherwise) which may affect your ability to respond adequately to an emergency?
For example, some medications may cause sleepiness or drowsiness which may affect a person's ability to react quickly or think clearly.
- YES
- NO
If YES, please provide details
Do you need any special assistance to fulfill the requirements above in a safe and different manner?
- YES
- NO
If YES, please provide details
Medical History
Have you broken any bones?
- YES
- NO
Do you suffer from, or have you in the past suffered from:
Please check those that apply.
- Bronchitis
- Diabetes
- Excessive noise exposure
- Dermatitis or skin conditions
- Fits or blackouts
- Asthma
- Hernia
- Allergies to latex, rubber or any chemicals
- Epilepsy or fainting
- Hearing problems
If YES, please provide details.
Have you tested positive to or been vaccinated against Q Fever?
- YES
- NO
If YES, Date

Day

Month

Year
If YES, Doctor/Company
Height
How would you rate your current fitness level?
Doctors Name
Clinic
Phone
Collection of personal information

The personal and health information in this application form, and any personal and health information obtained from a medical examination or test, is being collected by the Midfield Group of companies.

You can contact the Midfield Group by:
- calling (03) 5563 4444
- emailing us at midfield@midfield.com.au
- or posting correspondence to: PO Box 412, Warrnambool, Victoria 3280
You may be able to access the personal and health information we have collected about you. The Midfield Group Privacy Policy contains information about how you may be able to access that information and seek its correction if it is not correct. The Midfield Group Privacy Policy contains information about how you may complain about a breach of your privacy and how the Midfield Group will deal with your complaint.

The Midfield Group collects the personal and health information in this application form, and the personal and health information obtained from a pre-employment medical examination or test, for the purpose of assessing this application and any other job application you may make for employment with the Midfield Group in the next 12 months. The Midfield Group collects the personal and health information obtained from a medical examination or test during employment for the purpose of assessing your fitness for work and/or your ability to carry out the inherent requirements of the job.

The Midfield Group will not disclose your personal and health information to any 3rd parties, other than those indicated in your consent below, or in any other authorisation you have given us.

The Midfield Group does not disclose your personal and health information to any overseas recipients.

If you do not provide the personal and health information requested in this application form, or if you do not attend the pre-employment medical examination or testing, the Midfield Group will be unable to properly assess your employment application and consequently may not offer you employment.

If you do not attend a medical examination or testing during employment when requested, the Midfield Group may not be able to assess your fitness for work and/or your ability to carry out the inherent requirements of the job. In this instance, the Midfield Group may not be able to offer you duties, and your employment may be terminated.

Consent

I authorise "The Midfield Group" to forward my completed health history to a doctor or physiotherapist nominated by The Midfield Group to conduct my pre-employment medical examination. I authorise "The Midfield Group" to forward my completed health history to an audiologist nominated by The Midfield Group if I am required to take a hearing test. I give consent for the doctor and/or physiotherapist and/or audiologist to provide a report to The Midfield Group on my medical status.

I consent to The Midfield Group (1) using and disclosing, and (2) retaining for a period of 12 months, the personal and health information I have provided in this application form for the purpose of assessing this application and any other job application I make for employment with The Midfield Group in the next 12 months.

I understand all information provided will remain strictly confidential, I understand that false,
misleading, or undisclosed information could jeopardise my employment.
Signature*
Date*

Day

Month

Year

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