Occupational Health Service Pre-Employment Questionnaire

This form is for ABC staff. Please complete all sections as requested.

Personal Details

Please provide as much information as possible for any declared conditions.

DECLARATION: I declare that the information on this form is true and complete. I understand that any wilful misstatement or omission may render me liable to dismissal if engaged. I am prepared to undergo a medical examination and/or chest x-ray and attend Occupational Health within 4 weeks of commencing employment for immunisation if necessary. Disclosure of medical information to the examining Doctor by my present medical practitioner and any other who have examined me may be necessary and in these circumstances my permission will be sought in accordance with the Access to Medical Report Act 1988.

Please ensure you have completed and enclosed the relevant vaccination evidence, if required.