Health Statement - Mental Health & Disability Services Perth, WA

First Name *

Last Name *

Email *

1. IMMUNISATION HISTORY

Employee Information
Disease.	Have you ever had the disease? Yes/No/Unsure	Vaccinated against the disease? Yes/No/Unsure	Any blood test to confirm immunity? Yes/No
Data is updated every 15 minutes.
TB	YesNoUnsure	YesNoUnsure	YesNo
Hepatitis B	YesNoUnsure	YesNoUnsure	YesNo
Measles	YesNoUnsure	YesNoUnsure	YesNo
Mumps	YesNoUnsure	YesNoUnsure	YesNo
Rubella	YesNoUnsure	YesNoUnsure	YesNo
Varicella / Chicken Pox	YesNoUnsure	YesNoUnsure	YesNo
Pertussis (Whooping cough)	YesNoUnsure	YesNoUnsure	YesNo
Poliomyelitis	YesNoUnsure	YesNoUnsure	YesNo

MRSA: Have you worked or been a patient in a hospital outside WA in last 12 months?

YesNo

2. HEALTH ASSESSMENT

1. The applicable State Health and Safety Acts require that all parties involved with work have responsibilities for safety and health of self or others at work. IDune Health, as far as practicable, endeavour to ensure a work environment in which employees are safe and there are no risks to their health whilst at work.

2. As part of ensuring that all parties are safe and there are no health and safety risks to self or others whilst at work, employees will need to answer the questions below to aid in the allocation of suitable assignments. If you answered ‘YES’ to any of the questions, please give details including dates and how it affects you now. Continue on a separate sheet if necessary.

Disclaimer: Wilful and false representation by worker under Workers'
Compensation and Injury Management Act 1981/Sect 79.: Where it is proved
that the worker has, at the time of seeking or entering employment in
respect of which he claims compensation for an injury, wilfully and falsely
represented himself as not having previously suffered from the injury an
arbitrator may in the arbitrator’s discretion refuse to award compensation
which otherwise would be payable.

This information is confidential

1. Do you currently have any health problems that may put your safety or
others at risk?

2. Are you presently receiving any prescribed medication, treatment that
may impact on your ability to undertake your duties?

3. Do you have any health condition that may affect your ability to
perform your duties?

4. Do you have any health condition caused or made worse by manual
handling or repetitive tasks?

5. You have a duty to disclose any information that would restrict or
limit any work placements. Is there any further information that IDune
Health would require prior to employment?

Your Subject:

Additional Information

3. DECLARATION

I declare that the information in this form is true and complete to the best of my knowledge.

I also understand that any deliberate omission, falsification or misrepresentation by me to IDune
Health may be grounds for rejecting this application; my offer of employment may be withdrawn or
my employment terminated.

I consent to IDune Health collecting this information and using it for the purpose of my
employment.

I am aware of the risks of contracting disease during my employment within the acute health
setting.

By completing this form, you agree and consent to the Terms of Service here... and Privacy Statement here... .

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Acknowledgement of Country

iDune Health acknowledges the Traditional Custodians of Country throughout Australia and their connections to land, sea, and community. We pay our respect to their elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

Health and Capabilities Statement

Please Complete All The Parts of This Form*

1. IMMUNISATION HISTORY

2. HEALTH ASSESSMENT

This information is confidential

3. DECLARATION

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Acknowledgement of Country

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