PRE-EMPLOYMENT MEDICAL QUESTIONNAIRE

The aim of the Pre-Employment Medical (PEM) Questionnaire is to ensure that applicant’s physical and other related abilities are matched to the medical and fitness standards for the particular duties of a job.
Pre-Employment Medical Questionnaires (PEM’s) are necessary to determine that:

  • There is not risk of aggravating a pre-existing medical condition
  • The applicant is able to productively carry out the duties of the position safely
  • The applicant should not, because of a medical condition, increase risk to other workers, equipment, products or the general public.

CONFIDENTIALITY
The Pre-Employment Questionnaire is treated as a confidential document and access is limited to a ‘need to know’ basis. In the event of you being employed, Advanta Commercial Furniture will retain this form on a confidential file and reserve the right to refer to the information in the event of an accident, sickness, injury or claim for worker’s compensation. The information may also be used for other purposes, if so required by law.

IMPORTANT NOTICE
To assist Advanta Commercial Furniture in assessing your medical fitness for employment, you must answer the questions contained in this questionnaire truthfully and to the best of your knowledge.

Failure to disclose any relevant matter relating to your health may result in your not being employed by the employer or, if already employed by the employer, your employment may be affected and rights to workplace compensation compromised.

 

PEM

  • Personal Details

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  • MEDICAL HISTORY

  • Answer each question below

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  • Duration and dates of conditionCurrent status 
  • Have you been vaccinated against:

  • Drop files here or
    Max. file size: 128 MB.
    • DECLARATION

      I hereby declare that: - I have read and understood the conditions of this form. - I understand that the information I provide will be retained on my employee file and that the employer reserves the right to access and use the information in the event of any accident, injury, sickness or claim for workers compensation or for any other reasonable purposes, if so required by law. - I consent to Advanta Commercial Furniture and its medical representatives obtaining or exchanging further medical information from my treating doctors or other health practitioners, if required for the purposes of this assessment. - My answers relating to my medical and employment history are true and complete to the best of my knowledge. Furthermore there is nothing else regarding my health, well being ,or ability to carry out my potential role which Advanta Commercial Furniture or its medical advisers may need to know to assess me for the position(s) for which I have applied. - I am fully aware that if I fail to disclose any relevant matter relating to my health, which renders me incapable of properly fulfilling the duties of the position, the employer may not employ me or if already employed by the employer, my employment may be summarily terminated. - I understand and agree that this report and any related health information provided may be supplied to Advanta Commercial Furniture and its medical advisors.
    • DD dot MM dot YYYY

     

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