SESLHD Pre-Employment Health Declaration Form
Employment with the South Eastern Sydney Local Health District (SESLHD) is conditional on
the preferred applicant completing this statutory Pre-Employment Health Declaration form.
It is important that the SESLHD is made aware of any medical condition or other factors relating
to your health and physical fitness so that the organisation can ensure safe systems of work and
comply with its duty of care for all employees.
The pre-employment screening questionnaire relates to the applicant meeting the inherent
requirements of the position under consideration, and enables SESLHD to ensure safe systems
of work can be provided where pre-existing injuries and/or disease may be affected by
employment with SESLHD.
Only staff immediately involved in the recruitment and selection process will have access to this
information. A copy will be kept in a personnel file to assist with any emergencies, which may
arise during the course of your employment with SESLHD or for the assessment of any claim for
compensation to assist in the determination of liability.
The disclosure of information will not be used to discriminate against you because of the
existence of any such disability or medical condition.
Position applied for
Position Reference Number
Given Name(s)
Family Name or Surname
If your name has changed
please state your previous
name(s)
Email address for all
correspondence
Telephone No
Home……………………………………………………
Work…………………………………………………….
Mobile…………………………………………………..
SESLHD District Form F286
TRIM: T14/39243
Date: March 2017
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Pre-Employment Health Screening Questionnaire
Have you read the position description and familiarised yourself with the inherent physical and
psychological requirements of the role? Yes or No
Please answer each question by circling Yes or No
If YES please give details.
1
Are you currently being
treated for any medical
condition, illness, injury or
disability (physical or
psychological) that may
affect your ability to safely
perform the job that you
have applied for (in line with
the job demands checklist)?
If YES please give details
YES
NO
2
If YES please give details
Have you ever had back,
neck or other pain that
persisted for more than a
week?
3
Have you ever made a claim
for workers compensation in
Australia or overseas?
YES
NO
If YES please give details
YES
-
Date of Injury:
Employer at time of injury:
-
Insurer:
-
Nature of Injury:
NO

If YES please give details
If yes is the claim still
open/current?
YES
-
Current status of workers compensation claim:
-
Current medical certificate restrictions:
NO
SESLHD District Form F286
TRIM: T14/39243
Date: March 2017
2 of 4
Pre-Employment Health Screening Questionnaire
4
Have any of your previous
contracts of employment
been terminated on medical
grounds?
If YES please give details
YES
Date of termination –
NO
Name of employer -
5
Are you returning to the
workforce after an absence
of more than 2 years?
If YES please give details
YES
NO
6
Does the position you have
applied for involve
significantly more physical
components than your
previous role/s?
If YES please give details
YES
NO
7
Are you limited in any way by
a medical condition?
If YES please give details
YES
NO
8
Do you have hearing loss?
If YES please give details
YES
NO
SESLHD District Form F286
TRIM: T14/39243
Date: March 2017
3 of 4
Pre-Employment Health Screening Questionnaire
9
Do you suffer from dermatitis
or any other skin problems
If YES please give details
YES
Diagnosis:_______________________________________
NO
Are your hands and/or forearms affected? YES/NO
If Yes, do you require particular products to wash your
hands and/or forearms? YES/NO
If Yes, please name the products: ____________________
10
Do you have an injury or
underlying condition that
may impact on your ability to
carry out the position that
you have applied for (in line
with the job demands
checklist)?
If YES please give details
YES
NO
11
Please specify any other
condition not mentioned
previously that may be
aggravated whilst
undertaking the inherent
duties of this position.
If YES please give details
YES
NO
12. Please describe your level of comfort performing the following actions:
Activity
Difficult
Some
No
Comments
Difficulty
difficulty
Floor to waist level lifting 9kgs
Waist to eye level lifting 9kgs
Two handed carrying 9kgs
One handed carrying 5kgs
Pushing
Pulling
Prolonged sitting
Standing
Working with arms overhead
Working bent over - sitting
Squatting/crouching
SESLHD District Form F286
TRIM: T14/39243
Date: March 2017
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Pre-Employment Health Screening Questionnaire
Activity
Difficult
Some
Difficulty
No
difficulty
Comments
Climbing stairs
Walking
Trunk rotation - standing
Trunk rotation - sitting
13. How would you best describe your general health on the following scale:
1
Poor
2
3
4
5
Average
6
7
8
9
10
Excellent
DECLARATION:
I declare that I have answered all of the above questions correctly and that I have not withheld
any information regarding my past or present health.
I understand that a false declaration may result in any current or future contract of employment
with SESLHD being terminated.
I understand that by signing this form I authorise South Eastern Sydney Local Health District
(SESLHD) to release information to the pre-employment assessment team and in turn the preemployment assessment team to release information to the SESLHD either verbal or written, in
relation to the pre-employment assessment for which I may be referred.
If required, I am happy to provide any necessary information from my nominated treating doctor
to support my application for this position.
I agree to have a functional capacity evaluation if requested
Name………………………………………………………..
Signature…………………………………………………….
Date………………………………………………………….
Certified by Convenor:
 The form has been reviewed and the required action taken as per Section 5.3 of SESLHD
PR/370 Health Screening of Prospective Employees
Convenor
Name………………………………………………….Date………………………………………
Convenor Signature……………………………Email……………………………@health.nsw.gov.au
Department/Ward…………………………….……….Facility/Service….………………………………
SESLHD District Form F286
TRIM: T14/39243
Date: March 2017
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