Fit Slip - Workforce Express

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Fit Slip

Pre Placement Fit Slip

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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?
COVID-19 Vaccination Status*
The Australian Federal and State Governments have introduced requirements that employees working in particular industries and job positions be vaccinated with one or both doses of the COVID-19 vaccine. Some of our clients operate in these high risk and vulnerable industries and working environments and in order to protect the community require the vaccination status of employees to ensure they are complying with the Governments requirements. Should you give your consent, your vaccination status will only be disclosed to a client if and when they enquire and will otherwise remain confidential.
- Yes – I give my consent
- No – I do not give my consent
What is your COVID-19 vaccination status?*
- Vaccinated – 2 doses received
- Partially vaccinated – 1 dose received
- Not vaccinated – awaiting scheduled appointment
- Not vaccinated – medical exemption
- Not vaccinated – not intending to vaccinate
- Prefer not to disclose
COVID-19 Vaccine – Dose 1 Type*
Please indicate the vaccination type (example: AstraZeneca, Pfizer, Moderna or Other)
- AstraZeneca
- Pfizer
- Moderna
- Other
COVID-19 Vaccine – Dose 1 Date*
COVID-19 Vaccine – Dose 2 Type*
Please indicate the vaccination type (example: AstraZeneca, Pfizer, Moderna or Other)
- AstraZeneca
- Pfizer
- Moderna
- Other
COVID-19 Vaccine – Dose 2 Date*
When is your Vaccination Dose 1 Date scheduled?*
When is your Vaccination Dose 2 Date scheduled?*
Medical Exemption*
Please upload your Medical Exemption as a Word or PDF.
Max. file size: 256 MB.
Select below vaccinations you've received
Please enter the year vaccinated in the next section for any that you have, otherwise leave empty.
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Tetanus
- 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 Workforce Express immediately of any changes to this information. I agree to immediately notify Workforce Express 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 Workforce Express employment contract.

By signing this form I hereby give consent for the Workforce Express Rehabilitation Co-ordinator to contact my treating doctor and obtain any medical information relevant to any workplace incident that occurs while working for Workforce Express.
Form completed by*
First Last
Date*

Pre Placement Fit Slip

LinkedIn
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?
COVID-19 Vaccination Status*
The Australian Federal and State Governments have introduced requirements that employees working in particular industries and job positions be vaccinated with one or both doses of the COVID-19 vaccine. Some of our clients operate in these high risk and vulnerable industries and working environments and in order to protect the community require the vaccination status of employees to ensure they are complying with the Governments requirements. Should you give your consent, your vaccination status will only be disclosed to a client if and when they enquire and will otherwise remain confidential.
- Yes – I give my consent
- No – I do not give my consent
What is your COVID-19 vaccination status?*
- Vaccinated – 2 doses received
- Partially vaccinated – 1 dose received
- Not vaccinated – awaiting scheduled appointment
- Not vaccinated – medical exemption
- Not vaccinated – not intending to vaccinate
- Prefer not to disclose
COVID-19 Vaccine – Dose 1 Type*
Please indicate the vaccination type (example: AstraZeneca, Pfizer, Moderna or Other)
- AstraZeneca
- Pfizer
- Moderna
- Other
COVID-19 Vaccine – Dose 1 Date*
COVID-19 Vaccine – Dose 2 Type*
Please indicate the vaccination type (example: AstraZeneca, Pfizer, Moderna or Other)
- AstraZeneca
- Pfizer
- Moderna
- Other
COVID-19 Vaccine – Dose 2 Date*
When is your Vaccination Dose 1 Date scheduled?*
When is your Vaccination Dose 2 Date scheduled?*
Medical Exemption*
Please upload your Medical Exemption as a Word or PDF.
Max. file size: 256 MB.
Select below vaccinations you've received
Please enter the year vaccinated in the next section for any that you have, otherwise leave empty.
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Tetanus
- 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 Workforce Express immediately of any changes to this information. I agree to immediately notify Workforce Express 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 Workforce Express employment contract.

By signing this form I hereby give consent for the Workforce Express Rehabilitation Co-ordinator to contact my treating doctor and obtain any medical information relevant to any workplace incident that occurs while working for Workforce Express.
Form completed by*
First Last
Date*

Phone
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?
COVID-19 Vaccination Status*
The Australian Federal and State Governments have introduced requirements that employees working in particular industries and job positions be vaccinated with one or both doses of the COVID-19 vaccine. Some of our clients operate in these high risk and vulnerable industries and working environments and in order to protect the community require the vaccination status of employees to ensure they are complying with the Governments requirements. Should you give your consent, your vaccination status will only be disclosed to a client if and when they enquire and will otherwise remain confidential.
- Yes – I give my consent
- No – I do not give my consent
What is your COVID-19 vaccination status?*
- Vaccinated – 2 doses received
- Partially vaccinated – 1 dose received
- Not vaccinated – awaiting scheduled appointment
- Not vaccinated – medical exemption
- Not vaccinated – not intending to vaccinate
- Prefer not to disclose
COVID-19 Vaccine – Dose 1 Type*
Please indicate the vaccination type (example: AstraZeneca, Pfizer, Moderna or Other)
- AstraZeneca
- Pfizer
- Moderna
- Other
COVID-19 Vaccine – Dose 1 Date*
COVID-19 Vaccine – Dose 2 Type*
Please indicate the vaccination type (example: AstraZeneca, Pfizer, Moderna or Other)
- AstraZeneca
- Pfizer
- Moderna
- Other
COVID-19 Vaccine – Dose 2 Date*
When is your Vaccination Dose 1 Date scheduled?*
When is your Vaccination Dose 2 Date scheduled?*
Medical Exemption*
Please upload your Medical Exemption as a Word or PDF.
Max. file size: 256 MB.
Select below vaccinations you've received
Please enter the year vaccinated in the next section for any that you have, otherwise leave empty.
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Tetanus
- 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 Workforce Express immediately of any changes to this information. I agree to immediately notify Workforce Express 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 Workforce Express employment contract.

By signing this form I hereby give consent for the Workforce Express Rehabilitation Co-ordinator to contact my treating doctor and obtain any medical information relevant to any workplace incident that occurs while working for Workforce Express.
Form completed by*
First Last
Date*

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For Clients
Why Workforce Express
Capability Statement
Contact Us

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Search for:

Rockhampton

First Floor, 17 William Street, Rockhampton QLD 4700

07 4927 6007

reception@workforceexpress.com.au

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