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Fit Slip

Pre Placement Fit Slip

Name*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation*
Medical History
Have 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 state
Summary
In 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 position Enter 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*
Date Format: MM slash DD slash YYYY
Comments
This 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 Country
Occupation*
Medical History
Have 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 state
Summary
In 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 position Enter 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*
Date Format: MM slash DD slash YYYY
Name
This 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 Country
Occupation*
Medical History
Have 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 state
Summary
In 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 position Enter 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*
Date Format: MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Brisbane

Level 3, 172 Robertson Street, Fortitude Valley, Brisbane QLD 4006

07 3716 6600

info@ngage.com.au

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Home
For Candidates
For Clients
Why Engage
Capability Statement
Contact Us

Search

Search for:

Gladstone

Suite 2, 124 Goondoon Street, Gladstone QLD 4680

07 4972 9960

info@ngage.com.au

Newcastle

PO Box 137
Wangi Wangi NSW 2267

02 4967 3244

info@ngage.com.au

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Preferred position	Enter Yes or No

Preferred position	Enter Yes or No

Preferred position	Enter Yes or No

Pre Placement Fit Slip

Medical History

Do you have any difficulties performing the following activities?

Do you suffer from or have you ever suffered from:

Have you ever received the below vaccinations?

Summary

Pre Placement Fit Slip

Medical History

Do you have any difficulties performing the following activities?

Do you suffer from or have you ever suffered from:

Have you ever received the below vaccinations?

Summary

Medical History

Do you have any difficulties performing the following activities?

Do you suffer from or have you ever suffered from:

Have you ever received the below vaccinations?

Summary