APPLICANT DETAILS DOCUMENTATION TO SUPPORT APPLICATION

Transcription

1 [JOB APPLICATION] APPLICANT DETAILS SURNAME GIVEN NAME POSITION APPLIED F DOCUMENTATION TO SUPPT APPLICATION As a pre-requisite of employment with NPT, the following documentation is required to be completed and returned to NPT s Human Resource Department. Failure to supply the required documentation may result in a non-compliance of your application. DOCUMENTATION Pre-Employment Health Questionnaire Pre-Employment Immunisation Screening National Police Check Working with Children s Check Qualifications and Registrations REQUIREMENTS & INFMATION Included within this pack (F-HRM-422) Included within this pack (F-HRM-423) Where stated, evidence of immunisations must also be supplied with the completed form. Certified copy of a National Police Check which has been obtained within the last 6 months. The National Police Check should indicate position type: e.g. Patient Transport Officer, Ambulance Attendant, Registered Nurse etc. Certified copy of a Working with Children s Check (WWC). The WWC must be an employee check rather than a Volunteer Check. If you do not currently have a WWC, please note that they can take up to 1 month to be completed. Once your application has been lodged with the relevant state authority, please supply a copy of the application and receipt of payment as evidence. Certified copy of any applicable Qualification (Certificate, Diploma or Degree) or Registration (e.g. AHPRA Registration) associated with the position being applied for. Note: It is the responsibility of the job applicant to cover any charges or fees related to obtaining any of the required documentation above. Please return completed forms and certified copies (please note that documents that have not been certified may not be accepted by NPT) of the required document to: NPT Group Att: Human Resources Hardner Road Mt Waverley, Vic, careers@nptgroup.com.au

2 [JOB APPLICATION] PERSONAL INFMATION PLEASE PRINT SURNAME GIVEN NAME ADDRESS SUBURB CONTACT NUMBER POSTCODE DATE OF BIRTH DRIVERS LICENCE No: Expiry Date: Licence Type: EMERGENCY CONTACT DETAILS NAME NUMBER RESIDENCY STATUS CITZENSHIP Australian Citizenship VISA Permanent / Temporary Resident New Zealand Citizenship Working / Student POSITION DETAILS POSITION APPLYING F EMPLOYMENT TYPE Permanent Full Time Permanent Part Time Casual : No. of hrs SHIFT LOCATION SHIFT AVAILABILITY Day Afternoon Weekend AVAILABLITY COMMENTS AVAILABLE START DATE QUALIFICATIONS / REGISTRATIONS QUALIFICATION Certificate III in Non Emergency Patient Transport Diploma of Paramedical Science : No: of Clinical Supervised Hours completed: Bachelor of Nursing : AHPRA # : Other : Specify DATE ACHIEVED INSTITUTION

3 ADVICE F PROSPECTIVE EMPLOYEES You are about to complete a Pre-Placement Health Questionnaire. Are you in any way aware of any pre-existing injury or disease that may be affected by the nature of the proposed job? If so, please detail this on the questionnaire. You are also required to complete the Employee Declaration of pre-existing injury. If you fail to disclose or make a false or misleading disclosure, any recurrence, aggravation, acceleration, exacerbation or deterioration of the pre-existing injury/disease may not entitle you to compensation. The Pre-Placement questionnaire and medical examinations relate to the inherent requirements of the position applied for, and only assess current ability to perform the related duties whilst satisfying Occupational Health and Safety obligations. Results are used to assist with determining suitability to the position applied for, and are not the sole criterion used to make employment decisions. Additionally, in the event of a medical examination being required, the medical assessment involves the assessment of the functions of parts of the body relevant to the position for which you have applied. You may also be required to undergo a drug or alcohol screening test. The questionnaire and tests do not attempt to predict future deterioration, nor discriminate against people with disabilities, impairment or illness. Ways of accommodating people without all required physical attributes will be considered in determining suitability. The questionnaire and medical test results are confidential records. These will be maintained by NPT and the relevant medical service provider, and will not be released to other parties without the consent of the employee unless otherwise required by law. If you have any objection to completing a pre-employment health questionnaire and, if determined as necessary, a pre-placement medical examination, please advise the interviewer.

4 APPLICANT CONSENT I hereby consent to undertaking a preplacement health questionnaire and, if deemed necessary, undertaking a Pre Employment Medical Assessment with a nominated service provider. I further declare that the information I provide will be a true and correct account of my past and present medical history. I authorise the examining professional to make a recommendation to my prospective employer as to my suitability for the position. As a prospective employee, I understand that any incorrect or misleading statements or omissions may render me ineligible for appointment. I also authorise the nominated medical assessor to contact my personal doctor for further information if required for the purposes of this health questionnaire. My personal doctor s details are: Doctor s Name: Doctor s Telephone Number: APPLICANT INFMATION You are about to undergo a pre-placement questionnaire. Are you in any way aware of any preexisting injury or disease that may be affected by the nature of the proposed job? Please tick the appropriate box: YES If you answered YES, please provide details: NO Reminder: If you fail to disclose or make a false or misleading disclosure, any recurrence, aggravation, acceleration, exacerbation or deterioration of the pre-existing injury / disease may not entitle you to compensation.

5 1. MEDICAL HISTY MEDICAL CONDITION YES NO DETAILS 1. Cancer, Tumour 2. Varicose Veins, Blocked Arteries, Clots, Blood Disorder 3. Hernia 4. Blackouts, Fits, Faints, Epilepsy, Spasms, Dizziness, Giddiness 5. Persistent or Severe Headaches, Migraines 6. Head Injury, Brain Injury, Concussion 7. Arthritis, Rheumatism, Other Joint Illnesses 8. Hepatitis, Jaundice 9. Stomach Ulcers, Indigestion, Pancreatitis, Bowel Problems, Other Abdominal Disorders 10. Kidney Problems, Overactive or Underactive Thyroid Gland, Bladder Problems 11. Nervous Disorder, Claustrophobia, Depression, Anxiety, Other Stress Related Disorders 12. Eczema, Psoriasis, Dermatitis, Other Skin Disorders 13. Diabetes, High Cholesterol 14. Liver Disease 15. Prostate Problems, Hysterectomy, Pregnancy 16. Congenital Defects, Disorders 17. Degenerative diseases / disorders 2. GENERAL HEALTH HEALTH RELATED QUESTIONS YES NO DETAILS 1. Does any health problem restrict your activities of daily living? 2. Do you have any allergies (e.g. hayfever, food products, chemicals or medication)? 3. Do you suffer from any condition that requires regular medical review or time away from work for treatment or rest? 4. Do you have any communicable disease (e.g., hepatitis A, B, C, HIV/AIDS) or problem that may impair your ability to perform the job you are applying for or may affect other co-workers? 5. Do you suffer from any condition that may cause drowsiness or impair your concentration? 6. Is there any medical or health reason that would prevent you from working shift work? 7. Has your doctor advised you against taking any employment because it may put you at risk?

6 3. RESPIRATY FUNCTION HEALTH RELATED QUESTIONS YES NO DETAILS 1. Have you ever suffered from: Asthma Bronchitis Pneumonia Pleurisy Emphysema Tuberculosis Industrial Lung Disease Other respiratory disorders? 2. Do you experience shortness of breath when resting? 3. Do you experience shortness of breath with minimal exercise such as walking up a slight hill? 4. Have you ever had attacks of shortness of breath or wheezing? 5. Does your chest ever feel tight or your breathing becomes difficult? 4. CARDIOVASCULAR FUNCTION AND PHYSICAL ACTIVITY HEALTH RELATED QUESTIONS YES NO DETAILS 1. Have you ever suffered from: Heart Disease Heart Attack Stroke High Blood Pressure Heart Palpitations Other heart illnesses? 2. How often do you exercise for 20 minutes or more? Never 1-2 x per week > 3 x per week 3. Has your doctor ever said that you should only engage in physical activity recommended by a doctor? 4. Is your doctor currently prescribing drugs (e.g., aspirin) for your blood pressure or heart condition? 5. Do you ever feel pain in your chest when you engage in physical activity? 6. Do you lose balance because of dizziness, or do you ever lose consciousness when engaging in physical activity? 7. Do you know for any other reason why you should not engage in physical activity?

7 5. DRUGS AND MEDICATION HEALTH RELATED QUESTIONS YES NO DETAILS 1. Are you a current smoker or ex-smoker Current cigarettes per day: 2. Do you consume alcohol? Alcoholic drinks per day / per week: 3. Are you currently taking any prescription medication? Type: 4. Are you currently taking any non-prescription medication or remedies? Type: 6. MUSULOSKELETAL HISTY NECK YES NO Have you every injury or experienced pain in your neck? If YES to any of the above, please answer the following: Consulted a medical practitioner? YES NO Resulted in time off work? YES NO Surgery required? YES NO Ongoing problems? YES NO Approximate date occurred: Additional info: BACK YES NO Have you every injury or experienced pain in your back? If YES to any of the above, please answer the following: Consulted a medical practitioner? YES NO Resulted in time off work? YES NO Surgery required? YES NO Ongoing problems? YES NO Approximate date occurred: Additional info: SHOULDER, ELBOW, WRIST & HANDS YES NO Have you every injury or experienced pain in your shoulders, elbows, wrists or hands? i.e. sprain / stain / fracture / tendonitis / epicondylitis / carpal tunnel syndrome etc. If YES to any of the above, please answer the following: Consulted a medical practitioner? YES NO Resulted in time off work? YES NO Surgery required? YES NO Ongoing problems? YES NO Approximate date occurred: Additional info: HIPS, KNEES, ANKLES & LEGS YES NO Have you every injury or experienced pain in your hips, knees, ankles or legs? i.e. sprain / stain / fracture / tendonitis? If YES to any of the above, please answer the following: Consulted a medical practitioner? YES NO Resulted in time off work? YES NO Surgery required? YES NO Ongoing problems? YES NO Approximate date occurred: Additional info:

8 7. FUNCTION HISTY ACTIVITIES YES NO 1. Do you have any pain or discomfort when lifting or handling heavy objects? 2. Do you have any knee pain when squatting or kneeling? 3. Do you have any back pain when bending forward or twisting? 4. Do you have any pain or difficulty when lifting objects above your shoulder height? 5. Do you have any pain when doing any of the following for PROLONGED PERIODS (please circle appropriate response? Walking YES / NO Standing YES / NO Sitting YES / NO Squatting YES / NO Kneeling YES / NO Bending YES / NO 6. Do you have any pain when gripping or squeezing objects? 7. Do have any difficulties operating mobile phones or computerised equipment? 8. Do you have any difficulties travelling in a vehicle for longer than 20 minutes at a time? 9. Is there any reason why you cannot wear safety or protective equipment (e.g. gloves, safety glasses) 10. Do you anticipate that you will require assistance, in the form of specific aids or task modification, in order to undertake the essential components of the job applied for? If YES to any of the above, please explain: DECLARATION AND INFMATION CONSENT 1. Do you have any other medical, physical or health problems that you have NOT outlined within this questionnaire? If YES, please provide details: YES NO 2. Do you foresee experiencing any physical, medical or health related difficulties performing the position you are applying for? If YES, please provide details: I declare that the answers and information given in this questionnaire are true and correct to the best of my knowledge and I have not willingly omitted any information Printed Name: Signed: Date:

9 [PRE-EMPLOYMENT IMMUNISATION & SCREENING] ADVICE F PROSPECTIVE EMPLOYEES 1. It is a requirement of your employment with National Patient Transport that you complete a preemployment screening and immunisation assessment. This is to ensure that compliance with current Australian Infection Control and Occupational Health Requirements is met in order to protect you and the patients transported from exposure to vaccine preventable diseases. 2. Acceptable evidence of protection against specified diseases includes: A written record of vaccination signed by the medical practitioner, and / or Serological confirmation of protection, and / or Other evidence as specified in the table below. 3. TST screening is required if the person was born in a country with a high incidence of TB, or has resided for a cumulative time of 3 months or longer in a country with a high incident of TB, as listed at: EVIDENCE REQUIRED TO DEMONSTRATE PROTECTION DISEASE Diphtheria, tetanus, pertussis (whooping cough) Hepatitis B Measles, mumps, rubella (MMR) Varicella (chickenpox) Tuberculosis (TB) Refer to Note 3 for people requiring TST screening Influenza EVIDENCE OF VACCINATION One adult dose of diphtheria / tetanus / perussis vaccine (dtpa). Not ADT. History of completed age-appropriate course of hepatitis B vaccine. Not accelerated course. 2 doses of MMR vaccine at least one month apart AND DOCUMENTED SEROLOGY RESULTS Serology will not be accepted Anti-HBs greater than or equal to 10 mlu/ml Positive IgG for measles, mumps and rubella OTHER ACCEPTABLE EVIDENCE Not applicable Documented evidence of anti-hbc, indicating past hepatitis infection Birth date before doses of varicella vaccine at least one month apart (evidence of one dose is sufficient if the person was vaccinated before 14 Positive IgG for varicella History of chickenpox or physician diagnosed shingles (serotest if uncertain) years of age) Not applicable Not applicable Tuberculin skin test (TST) Annual influenza vaccination is not a requirement but is strongly recommended National Patient Transport Page 9 of 11 Issue Date: 23/02/2017

10 [PRE-EMPLOYMENT IMMUNISATION & SCREENING] NEW EMPLOYEE UNDERTAKING / DECLARATION All new employees must complete each part of the New Employee Undertaking / Declaration Form and the Tuberculosis (TB) Screening Assessment and return these forms to NPT as soon as possible. NPT will assess these forms along with evidence of protection against the infectious diseases outlined in NPT s Staff Health Protocols. New employees will not be permitted to commence duties if they have not submitted this form. Failure to complete outstanding hepatitis B or TB requirements within the appropriate timeframe(s) will result in serious consequences and may affect the new employee s employment status. PART 1 PART 2 PART 3 PART 4 PART 5 I understood the requirements regarding workers within the non-emergency transport industry being classified as Category A healthcare workers and are therefore required to provide evidence of the serological immunity or vaccination history. Acceptable evidence includes a written record of vaccination signed their medical practitioner or vaccination provider. This does not include a statutory declaration. I undertake to participate in the assessment, screening and vaccination process and I am not aware of any personal circumstances that would prevent me from completing these requirements I undertake to participate in the assessment, screening and vaccination process, however I am aware of medical contraindications that may prevent me from fully completing these requirements and am able am able to provide documentation of these medical contraindications. I request consideration of my circumstances. I have evidence of protection for: pertussis diphtheria tetanus varicella measles mumps rubella I have evidence of protection for hepatitis B I have received at least the first dose of hepatitis B vaccine (documentation provided) and undertake to complete the hepatitis B vaccine course (as recommended in the Australian Immunisation Handbook, current edition) and provide a post-vaccination serology result within six months of appointment / commencement of duties. I have been informed of, and understand, the risks of infection, the consequences of infection and management in the event of exposure and agree to comply with the protective measures required by NPT. DECLARATION I declare that the information I have provided is correct NAME SIGNATURE DATE National Patient Transport Page 10 of 11 Issue Date: 23/02/2017

11 [PRE-EMPLOYMENT IMMUNISATION & SCREENING] TUBERCULOSIS (TB) ASSESSMENT TOOL A new employee will require TST screening if he/she was born in a country with a high incidence of TB, or has resided for a cumulative time of 3 months or longer in a country with a high incidence of TB, as listed at: CLINICAL HISTY Cough for longer than 2 weeks YES NO Please provide information below if you have any of the following symptoms: Haemoptysis (coughing blood) Fevers / Chills / Temperatures Night Sweats Fatigue / Weakness Anorexia (loss of appetite) Unexplained Weight Loss Have you ever had: Contact with a person known to have TB? YES NO If yes, provide details below: YES NO YES NO YES NO YES NO YES NO YES NO ASSESSMENT RISK OF TB INFECTION Were you born outside Australia? YES NO If yes, where were you born?. Have you lived or travelled overseas? Country Have you ever had: TB Screening? YES NO Amount of time YES NO If yes, provide details below and attach documentation: If you answered YES to any of the questions above, please provide details (attach extra pages if required) DECLARATION I declare that the information I have provided is correct NAME SIGNATURE DATE National Patient Transport Page 11 of 11 Issue Date: 23/02/2017