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?*YesNoAre you currently being treated by a doctor?*YesNoHave you ever had any problems relating to the use of safety or personal protective equipment?*YesNoAre you taking any medication that the employer should know about?*YesNoDo you have a history of any medical conditions that may affect your ability to work?*YesNoDo you have any current medical conditions that may affect your ability to work? (e.g. pregnancy, epilepsy)*YesNoAre you required to wear glasses for your work?*YesNoIf so, do you have prescription safety glasses?YesNoDo you consent to submit samples for pre-employment, random & post incident/accident/injury drug & alcohol screens?*YesNoDo you have any difficulties performing the following activities?Running or walking short distances*YesNoManoeuvring on uneven terrain*YesNoSharp or sudden body movements*YesNoUsing hand tools in excess of 5kg*YesNoLong periods of concentration*YesNoHearing*YesNoReading*YesNoClimbing*YesNoCrouching*YesNoWorking at heights*YesNoWorking in confined spaces*YesNoLifting or bending*YesNoAbility to grasp objects firmly with both or either hands for short & long periods*YesNoRepetitive body movements*YesNoSitting or standing for sustained periods*YesNoUnderstanding/communicating in English*YesNoFollowing clear instructions*YesNoDo you suffer from or have you ever suffered from:Asthma or lung related problems*YesNoHigh blood pressure or heart related issues*YesNoRepetitive strain*YesNoJoint problems/fractures/arthritis*YesNoBack or neck related problems*YesNoAny skin disorders*YesNoPersistent headaches/migraines*YesNoEar infections that resulted in a partial or complete loss of hearing*YesNoColour Blindness*YesNoStomach problems / Ulcers*YesNoHernias*YesNoFits or Seizures*YesNoAllergic reactions*YesNoMedical or surgical complications*YesNoLong periods of absenteeism from work*YesNoDiabetes*YesNoTuberculosis*YesNoHepatitis or Liver trouble*YesNoHave you ever received the below vaccinations?Please enter the year vaccinated for any that you have, otherwise leave empty.Hepatitis AHepatitis BTetanusHepatitis CQFeverOther – 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?*YesNoIf 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 CommentsThis 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?*YesNoAre you currently being treated by a doctor?*YesNoHave you ever had any problems relating to the use of safety or personal protective equipment?*YesNoAre you taking any medication that the employer should know about?*YesNoDo you have a history of any medical conditions that may affect your ability to work?*YesNoDo you have any current medical conditions that may affect your ability to work? (e.g. pregnancy, epilepsy)*YesNoAre you required to wear glasses for your work?*YesNoIf so, do you have prescription safety glasses?YesNoDo you consent to submit samples for pre-employment, random & post incident/accident/injury drug & alcohol screens?*YesNoDo you have any difficulties performing the following activities?Running or walking short distances*YesNoManoeuvring on uneven terrain*YesNoSharp or sudden body movements*YesNoUsing hand tools in excess of 5kg*YesNoLong periods of concentration*YesNoHearing*YesNoReading*YesNoClimbing*YesNoCrouching*YesNoWorking at heights*YesNoWorking in confined spaces*YesNoLifting or bending*YesNoAbility to grasp objects firmly with both or either hands for short & long periods*YesNoRepetitive body movements*YesNoSitting or standing for sustained periods*YesNoUnderstanding/communicating in English*YesNoFollowing clear instructions*YesNoDo you suffer from or have you ever suffered from:Asthma or lung related problems*YesNoHigh blood pressure or heart related issues*YesNoRepetitive strain*YesNoJoint problems/fractures/arthritis*YesNoBack or neck related problems*YesNoAny skin disorders*YesNoPersistent headaches/migraines*YesNoEar infections that resulted in a partial or complete loss of hearing*YesNoColour Blindness*YesNoStomach problems / Ulcers*YesNoHernias*YesNoFits or Seizures*YesNoAllergic reactions*YesNoMedical or surgical complications*YesNoLong periods of absenteeism from work*YesNoDiabetes*YesNoTuberculosis*YesNoHepatitis or Liver trouble*YesNoHave you ever received the below vaccinations?Please enter the year vaccinated for any that you have, otherwise leave empty.Hepatitis AHepatitis BTetanusHepatitis CQFeverOther – 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?*YesNoIf 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 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?*YesNoAre you currently being treated by a doctor?*YesNoHave you ever had any problems relating to the use of safety or personal protective equipment?*YesNoAre you taking any medication that the employer should know about?*YesNoDo you have a history of any medical conditions that may affect your ability to work?*YesNoDo you have any current medical conditions that may affect your ability to work? (e.g. pregnancy, epilepsy)*YesNoAre you required to wear glasses for your work?*YesNoIf so, do you have prescription safety glasses?YesNoDo you consent to submit samples for pre-employment, random & post incident/accident/injury drug & alcohol screens?*YesNoDo you have any difficulties performing the following activities?Running or walking short distances*YesNoManoeuvring on uneven terrain*YesNoSharp or sudden body movements*YesNoUsing hand tools in excess of 5kg*YesNoLong periods of concentration*YesNoHearing*YesNoReading*YesNoClimbing*YesNoCrouching*YesNoWorking at heights*YesNoWorking in confined spaces*YesNoLifting or bending*YesNoAbility to grasp objects firmly with both or either hands for short & long periods*YesNoRepetitive body movements*YesNoSitting or standing for sustained periods*YesNoUnderstanding/communicating in English*YesNoFollowing clear instructions*YesNoDo you suffer from or have you ever suffered from:Asthma or lung related problems*YesNoHigh blood pressure or heart related issues*YesNoRepetitive strain*YesNoJoint problems/fractures/arthritis*YesNoBack or neck related problems*YesNoAny skin disorders*YesNoPersistent headaches/migraines*YesNoEar infections that resulted in a partial or complete loss of hearing*YesNoColour Blindness*YesNoStomach problems / Ulcers*YesNoHernias*YesNoFits or Seizures*YesNoAllergic reactions*YesNoMedical or surgical complications*YesNoLong periods of absenteeism from work*YesNoDiabetes*YesNoTuberculosis*YesNoHepatitis or Liver trouble*YesNoHave you ever received the below vaccinations?Please enter the year vaccinated for any that you have, otherwise leave empty.Hepatitis AHepatitis BTetanusHepatitis CQFeverOther - 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?*YesNoIf 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 PhoneThis field is for validation purposes and should be left unchanged.