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Medical Form Update

Educator Details

Educator First Name*
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Educator Last Name*
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Educator Email*
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Medical History

Do you have or have you ever had:

Allergies, including to drugs; animals; bee stings; pollens; grass; food; rubber; chemical*
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Heart conditions (heart attacks; angina; high/low blood pressure; murmur; palpitations; chest pain, etc)*
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Field is required!
Stroke; clots in legs or lungs; excessive bleeding or bruising; DVT; varicose veins:*
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Field is required!
Nervous System Disorder (paralysis; blackouts; dizzy spells; fainting or attacks of unconsciousness; epilepsy; muscular weakness; numbness in fingers/hands; coordination problems):*
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Field is required!
Eye conditions (restricted vision; Glaucoma Iritis; colour blindness; other)*
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Field is required!
Ear conditions; restricted hearing; tinnitus; ear infections; hearing loss; hearing difficulties*
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Skin conditions (Eczema; Dermatitis; rash; Psoriasis; recent skin infection; Skin Cancer)*
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Lung Conditions (Asthma; Bronchitis; Pleurisy; Tuberculosis; coughing up blood; persistent cough; chest complaints; shortness of breath; Silicosis; Asbestosis; other)*
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Digestive system conditions (Colitis; frequent diarrhoea; Gastric/Duodenal Ulcer; IBS; Hepatitis; Liver complaints / Jaundice; pancreatitis)*
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Field is required!
Migraine; persistent headaches; head injury; concussion*
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Sleep disorder; Issues with sleep or excessive fatigure when performing shift work?*
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Chronic fatigue lasting greater than 6 weeks*
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Field is required!
Take medication to help you sleep or remain alert or awake?*
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Rheumatic fever*
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Kidney / Bladder conditions (kidney stones; urinary infection; prostate problem)*
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Field is required!
Arthritis, gout, joint pain or swelling*
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Field is required!
Feet problems, ankle problems or foot pain when standing or walking*
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Field is required!
Knee injury, swelling or pain*
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Field is required!
Shoulder pain, tendonitis or frozen shoulder*
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Field is required!
Back / Neck problems (disc problems; prolonged back/neck pain; whiplash; sciatica or leg pain)*
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Field is required!
Broken bones or fractures*
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"Repetitive strain injury" such as tendonitis, tennis elbow, golfers elbow, Carpal tunnel syndrome or any other over use condition*
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History of Tropical / Infectious Diseases including Malaria; Hepatitis; Tuberculosis (TB), Dengue Fever*
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Diabetes or thyroid problem (over/under active thyroid)*
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Cancer or other tumours*
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Mental Illness / stress (nervous breakdown; mental fatigue; anxiety; depression; panic attacks; self-harm; significant sleep disturbance; eating disorders; fear; phobias to travel or confined spaces; schizophrenia; bipolar)*
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A pace maker or any other implantable device*
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Are you receiving medical treatment at the present time that an employer should know about?*
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Do you currently have any work restrictions certified by a Doctor?*
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Do you take regular medication?*
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Other conditions that may require medical management onsite (relevant to remote locations)*
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Hold a conditional Driver's License (with restrictions or conditions due to a medical condition), or have a condition you should report to the licensing authority?*
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Work Related Health History

Have you ever had (or currently have) any injury / illness / disease, whether physical or mental, that could affect your ability to perform this role?*
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Field is required!
Have you ever experienced conflict or stress at work that required medical treatment or counselling?*
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Have you ever left, or been denied a job on health grounds?*
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Have you ever been advised for medical reasons, not to do night work, shift work, or any other kind of work?*
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Have you ever lodged a Workers Compensation Claim?*
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Do you have a current Workers Compensation Claim?*
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Vaccination History

Have you had the following?

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Have you had or are you willing to get the following vaccinations if required?

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Social History

Do you currently smoke?*
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Extra Details

Do you have difficulties with the following activities?

Kneeling or crouching*
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Field is required!
Climbing stairs or ladders*
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Field is required!
Repetitive movement of hands or arms*
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Field is required!
Working in extremes of temperature*
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Field is required!
Concentrating on a task*
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Reading ordinary print*
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Hearing a normal conversation*
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Walking on rough or uneven ground*
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Standing or sitting for 2 hours or more*
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Lifting or bending*
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Gripping firmly with both hands*
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Confined spaces*
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Shift work*
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Turning your head rapidly*
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Stress Assessment

Given the nature of this role (working with complex youth autonomously), do you feel you have the emotional, mental, physical, and psychological fitness to perform this role?*
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If no, please provide additional information*
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Fatigue Assessment

Have you worked in a previous role that requires at least 10 hours of concentrated effort without a break?*
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If no, please provide additional information regarding how you believe you would cope*
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Medical Declaration Confirmation

Willful and false representation by an employee

- Where it is proved that the employee has, at the time of seeking or entering employment in respect of which the employee claims compensation for an injury, willfully and falsely represented themselves as not having previously suffered from the injury, the Agency may, at their discretion, refuse to award compensation which otherwise would be payable.

- Failure to answer all questions fully may invalidate the pre selection process and result in your application being disregarded.

- All medical information collected shall be held in strict confidence and in accordance with Privacy legislation.

I hereby certify that to the best of my knowledge and belief, the answers provided by me are true and correct*
I understand that any false or misleading information may result in termination of employment. I understand that I may also be required to provide copies of medical assessments/medical clearance/doctors/medical specialists letters during employment and on termination.
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Select a date
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