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Pre Employment Assessment

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Pre Employment Assessment Powered By Docstoc
					                                    ACTPS HEALTH ASSESSMENT FORM


PURPOSE
This form is to be used for pre-employment / appointment medical assessment, fitness for
duty / return to work medical assessment, medical assessment prior to overseas placement
and other medical assessment.

Under section 70 of the Public Sector Management Act 1994, a medical assessment is usually
required for permanent appointment to the ACT Public Service. Where an employee is to be
posted overseas it is a usual practice for a medical assessment to be carried out. In certain
circumstances, where there is a question about whether an employee is fit to carry out his or her
duties or return to duty, the Public Sector Management Standards authorise a direction to
undertake a medical assessment or the provision of a medical report (see Standard 3, Part 18,
rules 15-17 and Standard 4, Part 8, rule 4). The results of a medical assessment may also be
used to determine whether a person should be redeployed or retired by reason of disability under
sections 143-146 of the Public Sector Management Act 1994.

A medical examination will be conducted by the Preventive Medicine and Rehabilitation Centre
at 173 Strickland Crescent, Deakin (see attached map) at the date and time recorded below. If
you need to change the scheduled appointment you must advise the relevant Agency Contact
Officer listed at 1B at the earliest possible time.

PRIVACY
The Medical Adviser will provide this form and a medical report on the employee to the requesting
Agency specified below. The information in the form and the results of the medical examination
will be used for the employment purposes set out below. This is authorised by the
abovementioned provisions of the Public Sector Management Act and Public Sector Management
Standards.

As well as the Medical Adviser, the following members of the treating team will have access to this
form and the medical report (insert names or delete if
inappropriate)……………………………………..

A copy of the report is usually retained by the Preventive Medicine and Rehabilitation Centre.

The requesting Agency is bound by the provisions of the Health Records (Privacy and Access) Act
1997 (ACT), which protects the rights of consumers to privacy and access in relation to confidential
health information.

APPOINTMENT DETAILS

    Name of Employee …………………………………………………
    Date of appointment …………………… Time …………………………..


    Reason for referral                                 Pre employment Examination
    Requesting Agency                          ACT Health

    Contact for return of completed assessment: Shared Services Centre, Recruitment
     Services, GPO Box 158, Canberra City ACT 2601

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BEFORE THE MEDICAL EXAMINATION

    Carefully complete Section 2 before attending the medical examination. Do not sign the
     declaration at 2C until you are in the presence of the Medical Adviser.
    Bring the full Health Assessment Form with you to the medical examination, or if requested,
     return the completed Form and any supporting documentation to the Agency Contact Officer
     as soon as possible.
    If you are aware that you have any condition(s) which may require investigation or explanation,
     you should bring with you to the medical examination a statement from your doctor(s) about
     the condition(s), together with copies of any specialist reports, results of any medical tests or
     X-Rays.
    You should also bring with you to the medical examination your glasses or contact lenses if
     used, and details of any medication currently being taken.




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                    PERMISSION FORM TO RELEASE OR OBTAIN INFORMATION



I, ________________________ give my permission for the Preventive Medicine and Rehabilitation

Centre, to obtain and release any relevant information that will assist my medical

assessment/treatment/rehabilitation. This information can be obtained from or given to my General

Practitioner, treating Specialist, treating Health Professional/s, treating parties, Rehabilitation

Related Agencies, Insurance Company, Work Supervisor and Case Manager.




The Preventive Medicine and Rehabilitation Centre assures you that your personal health

information will be adequately stored, used and where necessary transferred in a secure manner

that protects your patient privacy, in compliance with the privacy legislation.



Please feel free to discuss any concerns, questions or complaints about any issues relating to the

privacy of your personal information.



Signed:

Date:




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                                    ACTPS HEALTH ASSESSMENT FORM

1. PERSONAL AND EMPLOYMENT DETAILS (to be completed by the Department / Agency)
A. Employee

Mr / Ms / Mrs
Surname           ______________________
Given Names ____________________                                  Date of Birth ___________
Male / Female
Classification (Attach Duty Statement / Job Description)
Worksite                   ACT Heath

B. Department / Agency

Department / Agency ACT Health Code:8069
Address: PO Box 11 WODEN ACT 2606
Name of Contact Officer              eRecruitment@act.gov.au
Return address for completed assessment form: Shared Services Centre, Recruitment
Services, GPO Box 158, Canberra City ACT 2601
Contact: Shared Services, Recruitment Services, Phone: 6205 5444

C. Appointment

Date and time of appointment                           ……………………………………………………..
Reason for referral: Pre-employment

D. Related Documents

Diagnosis(es) of treating doctor (if available) …………………………………………………..
Documents attached (Tick where applicable)
      report(s) from treating doctor(s)
      other relevant medical reports and certificates
      records of previous or current compensation claims (if authorised)
      history of sick leave
      work performance reports
      comments
      duty statement / job description

     Other documents attached (list) ……………………………………………………..
     ………………………………………………………………………………………………...

     Were these documents provided to the employee?

     Yes /No If No, reasons for withholding documents …………………………..
     ………………………………………………………………………………………………...



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2. EMPLOYMENT AND MEDICAL HISTORY (to be completed by the Employee)
A. Employment History

Details of previous employment (eg employer, type of work, duration, etc)
…………………………………………………………………………………………………………………
……………….…………………………………………………………………………………………………
……………………………….………………………………………………………………………………

Details of any work-related injuries or illnesses (if any)
…………………………………………………………………………………………………………………
……………….…………………………………………………………………………………………………
……………….………..……..…………………………………………………………………………………

Details of any previous Workers’ Compensation Claims (if any)
…………………………………………………………………………………………………………………
……………….…………………………………………………………………………………………………
……………………………….…………………………………………………………………………………

B. Medical History

Name and address of your usual Medical Practitioner ………………..………………………….

Medical Conditions (circle Yes or No for each of the following)

  Eye trouble                                 Yes / No               Stress Yes / No
  Loss of hearing                             Yes / No               Head injury/concussion                    Yes / No
  Nose/throat trouble                         Yes / No               Arthritis                                 Yes / No
  Wheezing/asthma                             Yes / No               Back pain/back injury/sciatica            Yes / No
  Tuberculosis                                Yes / No               Other joint injuries/conditions           Yes / No
  Other lung complaint                        Yes / No               Hernia (rupture)                          Yes / No
  High blood pressure                         Yes / No               Stomach pain/ulcer                        Yes / No
  Heart trouble/chest pain                    Yes / No               Passing or vomiting blood                 Yes / No
  Rheumatic fever                             Yes / No               Other abdominal complaint                 Yes / No
  Diabetes/endocrine disorder                 Yes / No               Liver disease/hepatitis                   Yes / No
  Cancer/tumour                               Yes / No               Kidney/Bladder trouble                    Yes / No
  Mental/nervous disorder                     Yes / No               Hay fever                                 Yes / No
  Blackouts/Fainting                          Yes / No               Dermatitis/eczema                         Yes / No
  Epilepsy/Fits                               Yes / No               Malaria/tropical disease                  Yes / No
  Frequent headaches/migraine                 Yes / No               Genetic disorder                          Yes / No

Are you currently using any regular medication? .........Yes / No (circle one)

If Yes, specify which medication(s): ................................................................................... ………
………………………………………………………………………………………………………………….


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2.    EMPLOYMENT AND MEDICAL HISTORY (Cont.)

Are you allergic to anything?                                                                                          Yes / No (circle one)

If Yes, specify which allergy(ies): ..................................................................................................
.......................................................................................................................................................

During the last five years, have you had any illnesses, operations, medical examinations,
investigations or X-Rays?
                                                                              Yes / No (circle one)
If Yes, please provide details in the space below.

 Date                         Name and address of Doctor                                      Reason




Are you aware of any medical conditions, which may prevent you from performing your duties in a
satisfactory manner in the ACT Pubic Service?
                                                                          Yes / No (circle one)
If Yes, please state them.
…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………

Have you ever smoked in the past?                                                                                      Yes / No (circle one)

         If Yes, how many cigarettes each day?

         Do you smoke now?                                                                                            Yes / No (circle one)


Do you drink alcohol?                                                                                                  Yes / No (circle one)

         Do you drink alcohol at least once each week?                                                                Yes / No (circle one)


Do you have any concerns regarding your health?                                                                        Yes / No (circle one)

C. Declaration

I have read the information contained in this form and understand the purpose and uses that may
be made of the report, and that the details provided in the form are, to the best of my knowledge,
true and complete. I authorise the examining Medical Adviser to release the information contained
in this form to the requesting Agency.


Signature of Employee                        …………………………………………..….. Date …………………

Signature of Examining Medical Adviser                              ………………………….…... Date.…………………




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3.   MEDICAL ADVISER’S REPORT (to be completed by the Examining Medical Adviser)

A. Comment on the Employee’s Medical History (any medical
   conditions / disorders which may either be aggravated by
   the nature of the employment or environment, or require
   treatment / stabilisation or necessitate job modifications)


…………………………………………………………………………………………………………………

B. Standard Tests


Height and weight:                          Ht …..….. cm Wt ……… kg
    BMI ………….


Physique:         Underweight            Normal        Overweight
                  Obesity                Morbid Obesity


                  BMI<20                 BMI 20-25           BMI 25-30
                  BMI 30-40              BMI>40


Urine Test       Albumin: Yes / No                Glucose: Yes / No         Blood: Yes / No
Vision          Right                Left


        Distance Vision: (without correction)                           6/……                        6/……


                               (with correction)                         6/……                        6/……


        Colour Vision:        (Ishihara test) Number of errors

Comments:
…………………………………………………………………………………………………………………
……………….…………………………………………………………………………………………………
……………………………….

C. Other Tests

Audiometry

     Ear / Hz            250          500         1000            2000     3000    4000       6000    8000
           R
           L

NORMAL / ABNORMAL
…………………………………………………………………………………………………………………..




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Respiratory function

Peak Flow Rate __________L/min

Spirometry (if indicated)             FEV1………..             FVC……….   FEV1/FVC………

Comments:
…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………




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D.   Medical Examination

Blood Pressure (lying down)                                       first reading………second reading ………..

…………………………………………………………………………………………………………………

Cardiovascular System (including peripheral veins)                     NORMAL /    ABNORMAL

…………………………………………………………………………………………………………………
Lungs                                                                  NORMAL /    ABNORMAL

…………………………………………………………………………………………………………………
Abdomen (including herniae)                                            NORMAL /    ABNORMAL

…………………………………………………………………………………………………………………
Lymph Nodes                                                            NORMAL /    ABNORMAL

…………………………………………………………………………………………………………………
Eyes                                                                   NORMAL /    ABNORMAL

…………………………………………………………………………………………………………………
Ear, Nose, Throat and Mouth                                            NORMAL /    ABNORMAL

…………………………………………………………………………………………………………………
Skin    NORMAL / ABNORMAL


………………………………………………………………………………
CNS (including balance and coordination)                               NORMAL /    ABNORMAL


………………………………………………………………………………
Endocrine System                                                       NORMAL /    ABNORMAL


………………………………………………………………………………
Musculoskeletal System


       Cervical Spine                 NORMAL / ABNORMAL
       Upper Limbs                 NORMAL / ABNORMAL
       Lower Limbs                    NORMAL / ABNORMAL


       Thoracolumbar Spine NORMAL / ABNORMAL


………………………………………………………………………………


Behaviour during the examination                                       NORMAL /    ABNORMAL

…………………………………………………………………………………………………………………

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Medical Disorders (if applicable)                                 NORMAL /   ABNORMAL

…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………

Comments (any abnormal medical findings / disorders which may either be aggravated by the
nature of the employment or environment, or require treatment / stabilisation or necessitate job
modifications)
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………




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4.   MEDICAL ADVISER’S RECOMMENDATION (to be completed by Examining Medical Adviser)

A. Employee / Appointment Details

Name of Employee           ………………..………..……………… Date of Birth ………….…………

Reason for Referral (Tick where applicable)
        pre-employment / appointment medical
        fitness for duty / return to work medical
        medical prior to overseas placement
        other (specify)                      ………………………………………………………………

Date of Examination …………………

B. Recommendation / Comments

Is the employee medically suitable to perform all prescribed duties? (Tick where applicable)
        Yes
        Requires Further Assessment (see comments below)
        No (see comments below)

Comments: If No, what type of duties / modified duties can the employee perform?
…………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………..

Fitness for Duty

If the employee is unfit to perform modified duties, is the employee fit for other duties?
                                                                               Yes / No
If so, what type of other duties can the employee perform? ……………………………..………..
…………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………..

If the employee is unfit to perform other duties, do you consider the employee to be totally and
permanently incapacitated for work?
                                                                               Yes / No
         (total and permanent incapacity means that because of a physical or mental condition the
         employee is unlikely to work again in a job for which the employee is reasonably qualified
         by education, training and experience or could be so qualified after retraining)

If the employee is not permanently incapacitated for work, should the employee be granted a
further period of sick leave?
                                                                         Yes / No
What reasonable action, including redeployment, retraining and work-based rehabilitation can be
taken by the Department / Agency or the employee to aid the employee’s return to work?
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………


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Where the employee signed an authority to provide medical information, did you obtain other
medical information from a treating doctor, specialist or hospital?
                                                                              Yes / No
If Yes, please attach details
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………


Reasons for recommendation (details of health / risk factors, medical conditions / disorders and the
effects on the employee’s capacity to work)
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………

Restrictions (details of recommended modifications to duties / equipment / work environment)
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………


Review / Referral (details of recommended review period, tests or referral)
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………


C. Certification

Signature of Examining Medical Adviser ……………………………………………………

Name of Examining Medical Adviser ……………………………………………………

Date                                                  ………………………….



   Stamp




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