Fit Slip Pre Placement Fit Slip Name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Occupation* Medical HistoryHave you ever suffered from any work related injuries or illness?* Yes No Are you currently being treated by a doctor?* Yes No Have you ever had any problems relating to the use of safety or personal protective equipment?* Yes No Are you taking any medication that the employer should know about?* Yes No Do you have a history of any medical conditions that may affect your ability to work?* Yes No Do you have any current medical conditions that may affect your ability to work? (e.g. pregnancy, epilepsy)* Yes No Are you required to wear glasses for your work?* Yes No If so, do you have prescription safety glasses? Yes No Do you consent to submit samples for pre-employment, random & post incident/accident/injury drug & alcohol screens?* Yes No Do you have any difficulties performing the following activities?Running or walking short distances* Yes No Manoeuvring on uneven terrain* Yes No Sharp or sudden body movements* Yes No Using hand tools in excess of 5kg* Yes No Long periods of concentration* Yes No Hearing* Yes No Reading* Yes No Climbing* Yes No Crouching* Yes No Working at heights* Yes No Working in confined spaces* Yes No Lifting or bending* Yes No Ability to grasp objects firmly with both or either hands for short & long periods* Yes No Repetitive body movements* Yes No Sitting or standing for sustained periods* Yes No Understanding/communicating in English* Yes No Following clear instructions* Yes No Do you suffer from or have you ever suffered from:Asthma or lung related problems* Yes No High blood pressure or heart related issues* Yes No Repetitive strain* Yes No Joint problems/fractures/arthritis* Yes No Back or neck related problems* Yes No Any skin disorders* Yes No Persistent headaches/migraines* Yes No Ear infections that resulted in a partial or complete loss of hearing* Yes No Colour Blindness* Yes No Stomach problems / Ulcers* Yes No Hernias* Yes No Fits or Seizures* Yes No Allergic reactions* Yes No Medical or surgical complications* Yes No Long periods of absenteeism from work* Yes No Diabetes* Yes No Tuberculosis* Yes No Hepatitis or Liver trouble* Yes No Have you ever received the below vaccinations?Please enter the year vaccinated for any that you have, otherwise leave empty.Hepatitis A Hepatitis B Tetanus Hepatitis C QFever Other – please stateSummaryIn the opinion of any “reasonable person” do you believe that you would have any problems performing the duties of that required to hold the position of?*Click the + button to add additional positions.Preferred positionEnter Yes or No Are there any other work related problems not mentioned that the employer should know about?* Yes No If yes, please state the other work related problems:I acknowledge all of the information provided is correct and that I will notify Engage immediately of any changes to this information. I agree to immediately notify Engage and the host employer of any workplace injuries, including near misses suffered at work. I accept and acknowledge that non- disclosure of any relevant medical information will result in an immediate termination of my Engage employment contract. By signing this form I hereby give consent for the Engage Rehabilitation Co-ordinator to contact my treating doctor and obtain any medical information relevant to any workplace incident that occurs while working for Engage.Form completed by* First Last Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Pre Placement Fit Slip Name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Occupation* Medical HistoryHave you ever suffered from any work related injuries or illness?* Yes No Are you currently being treated by a doctor?* Yes No Have you ever had any problems relating to the use of safety or personal protective equipment?* Yes No Are you taking any medication that the employer should know about?* Yes No Do you have a history of any medical conditions that may affect your ability to work?* Yes No Do you have any current medical conditions that may affect your ability to work? (e.g. pregnancy, epilepsy)* Yes No Are you required to wear glasses for your work?* Yes No If so, do you have prescription safety glasses? Yes No Do you consent to submit samples for pre-employment, random & post incident/accident/injury drug & alcohol screens?* Yes No Do you have any difficulties performing the following activities?Running or walking short distances* Yes No Manoeuvring on uneven terrain* Yes No Sharp or sudden body movements* Yes No Using hand tools in excess of 5kg* Yes No Long periods of concentration* Yes No Hearing* Yes No Reading* Yes No Climbing* Yes No Crouching* Yes No Working at heights* Yes No Working in confined spaces* Yes No Lifting or bending* Yes No Ability to grasp objects firmly with both or either hands for short & long periods* Yes No Repetitive body movements* Yes No Sitting or standing for sustained periods* Yes No Understanding/communicating in English* Yes No Following clear instructions* Yes No Do you suffer from or have you ever suffered from:Asthma or lung related problems* Yes No High blood pressure or heart related issues* Yes No Repetitive strain* Yes No Joint problems/fractures/arthritis* Yes No Back or neck related problems* Yes No Any skin disorders* Yes No Persistent headaches/migraines* Yes No Ear infections that resulted in a partial or complete loss of hearing* Yes No Colour Blindness* Yes No Stomach problems / Ulcers* Yes No Hernias* Yes No Fits or Seizures* Yes No Allergic reactions* Yes No Medical or surgical complications* Yes No Long periods of absenteeism from work* Yes No Diabetes* Yes No Tuberculosis* Yes No Hepatitis or Liver trouble* Yes No Have you ever received the below vaccinations?Please enter the year vaccinated for any that you have, otherwise leave empty.Hepatitis A Hepatitis B Tetanus Hepatitis C QFever Other – please stateSummaryIn the opinion of any “reasonable person” do you believe that you would have any problems performing the duties of that required to hold the position of?*Click the + button to add additional positions.Preferred positionEnter Yes or No Are there any other work related problems not mentioned that the employer should know about?* Yes No If yes, please state the other work related problems:I acknowledge all of the information provided is correct and that I will notify Engage immediately of any changes to this information. I agree to immediately notify Engage and the host employer of any workplace injuries, including near misses suffered at work. I accept and acknowledge that non- disclosure of any relevant medical information will result in an immediate termination of my Engage employment contract. By signing this form I hereby give consent for the Engage Rehabilitation Co-ordinator to contact my treating doctor and obtain any medical information relevant to any workplace incident that occurs while working for Engage.Form completed by* First Last Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Occupation* Medical HistoryHave you ever suffered from any work related injuries or illness?* Yes No Are you currently being treated by a doctor?* Yes No Have you ever had any problems relating to the use of safety or personal protective equipment?* Yes No Are you taking any medication that the employer should know about?* Yes No Do you have a history of any medical conditions that may affect your ability to work?* Yes No Do you have any current medical conditions that may affect your ability to work? (e.g. pregnancy, epilepsy)* Yes No Are you required to wear glasses for your work?* Yes No If so, do you have prescription safety glasses? Yes No Do you consent to submit samples for pre-employment, random & post incident/accident/injury drug & alcohol screens?* Yes No Do you have any difficulties performing the following activities?Running or walking short distances* Yes No Manoeuvring on uneven terrain* Yes No Sharp or sudden body movements* Yes No Using hand tools in excess of 5kg* Yes No Long periods of concentration* Yes No Hearing* Yes No Reading* Yes No Climbing* Yes No Crouching* Yes No Working at heights* Yes No Working in confined spaces* Yes No Lifting or bending* Yes No Ability to grasp objects firmly with both or either hands for short & long periods* Yes No Repetitive body movements* Yes No Sitting or standing for sustained periods* Yes No Understanding/communicating in English* Yes No Following clear instructions* Yes No Do you suffer from or have you ever suffered from:Asthma or lung related problems* Yes No High blood pressure or heart related issues* Yes No Repetitive strain* Yes No Joint problems/fractures/arthritis* Yes No Back or neck related problems* Yes No Any skin disorders* Yes No Persistent headaches/migraines* Yes No Ear infections that resulted in a partial or complete loss of hearing* Yes No Colour Blindness* Yes No Stomach problems / Ulcers* Yes No Hernias* Yes No Fits or Seizures* Yes No Allergic reactions* Yes No Medical or surgical complications* Yes No Long periods of absenteeism from work* Yes No Diabetes* Yes No Tuberculosis* Yes No Hepatitis or Liver trouble* Yes No Have you ever received the below vaccinations?Please enter the year vaccinated for any that you have, otherwise leave empty.Hepatitis A Hepatitis B Tetanus Hepatitis C QFever Other - please stateSummaryIn the opinion of any “reasonable person” do you believe that you would have any problems performing the duties of that required to hold the position of?*Click the + button to add additional positions.Preferred positionEnter Yes or No Are there any other work related problems not mentioned that the employer should know about?* Yes No If yes, please state the other work related problems:I acknowledge all of the information provided is correct and that I will notify Engage immediately of any changes to this information. I agree to immediately notify Engage and the host employer of any workplace injuries, including near misses suffered at work. I accept and acknowledge that non- disclosure of any relevant medical information will result in an immediate termination of my Engage employment contract. By signing this form I hereby give consent for the Engage Rehabilitation Co-ordinator to contact my treating doctor and obtain any medical information relevant to any workplace incident that occurs while working for Engage.Form completed by* First Last Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
