Pre Placement Fit Slip

Step 1 of 6

Name*

Email*

Address*

Date of Birth*

Occupation Applying For or Currently Working As:*

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

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*

Date*

Name

This field is for validation purposes and should be left unchanged.

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

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Brisbane

Gladstone

Newcastle