HEALTH DECLARATION FORM

For your and other’s health, please fill in the form truly and completely. False information of
intent will be followed with legal consequence.

I. PERSONAL INFORMATION

Last Name: ___________________ Given Name: _________________ Middle Initial: ______

Sex: Male Female Date of Birth (day/month/year): _________________

Age: ____________________________ Contact Number: _____________________________
Home Address: _________________________________________________________________
Body Temperature: __________________________ Pulse Rate: ________________________
Weight: _________ Height: _______________ Blood Pressure: _________________________

II. HEALTH INFORMATION

A.
NO YES If yes, please provide
details below:
a. Are you currently being
treated for any illness or
injury?
b. Are you currently or do
you regularly take any
medication/s?
c. Do you currently smoke
cigarettes?
d. Have you previously
smoked cigarettes?
e. Do you drink alcohol?
f. Is there a history of serious
illness or disease in your
immediate family?
*Your offspring, sibling(s),
parents and their siblings,
and grandparents
A. Do you suffer or have you ever suffered from any of the following: YES NO

Work related injury or illness ☐ ☐

Repetitive strain injury (RSI), occupational overuse syndrome (OOS), ☐ ☐
tennis elbow, pain syndrome or tenosynovitis
Mental or nervous condition, anxiety, stress reaction or depression ☐ ☐

Back, neck or spinal problems ☐ ☐

Asthma or hay fever ☐ ☐

Other allergies ☐ ☐

Tuberculosis, bronchitis, emphysema or any lung diseases ☐ ☐

Heart complaints or diseases, including high blood pressure ☐ ☐

Shortness of breath or chest pain ☐ ☐

Stomach or duodenal ulcers, or frequent indigestion ☐ ☐

Epilepsy, fainting attacks or fits of any kind ☐ ☐

Migraine or frequent headaches ☐ ☐

Bowel, liver, gall bladder, bladder or kidney diseases ☐ ☐

Cancer or tumor of any type ☐ ☐

Arthritis, gout or joint pains, or any other disorder of the muscles, joints ☐ ☐
or bones
Blood disorders ☐ ☐
Coughing of blood, or passing of blood from the bowel or blood in the ☐ ☐
urine
Defects in sight, speech, or hearing (not corrected by medical aids) ☐ ☐

Sugar in the urine or diabetes ☐ ☐

Skin disorders (other than an allergic reaction – refer to allergies) ☐ ☐

Infectious illness ☐ ☐

Hernia ☐ ☐

Head injury or concussion ☐ ☐

Other health complaints ☐ ☐

 YES NO
C. Do you have difficulty with any of the following:

Crouching/bending/ kneeling ☐ ☐

Sleeping ☐ ☐

Lifting heavy weights ☐ ☐

Standing for extended periods of time ☐ ☐

Travelling in light aircraft ☐ ☐

Walking up stairs or using ladders ☐ ☐

Repetitive movement hands/arms ☐ ☐

Working above shoulder height ☐ ☐

Sitting for extended periods of time ☐ ☐

If yes to any of the above, please provide details below:

Are you aware of any other health condition which may interfere with my ability to safely perform the
inherent requirements and demands of the position?

If yes, please provide details:

 III. DECLARATION (to be completed by applicant)

I understand that:
1. If I have a pre-existing condition I am obliged to disclose it if asked, so that my fitness to perform the
assigned duties can be assessed.
2. GBRMPA will make reasonable adjustments to the workplace to support employees with a disability.
3. I may be required to attend a medical examination or examinations or medical tests to determine my
suitability for employment and that may include authorizing any doctor who has attended or examined
me, or whom I have consulted, to disclose in writing to GBRMPA’s nominated medical practitioner,
information concerning my health.
4. If required to participate in a full medical clearance process, I may not be offered employment or have
my contract ceased under the Public Service Act 1999 on the grounds that I have failed to meet the
condition imposed under subsection 22(6) of the Public Service Act 1999.
5. If I do not complete and submit this health declaration form, I will not be considered for casual (irregular
or intermittent) employment.
I declare that:

1. All answers in this Health Declaration Form are true and correct to the best of my knowledge and belief.
2. I have not failed to supply any information nor provided false information.
3. I have read the description of the role and am aware of and able to meet the inherent job requirements
and demands of the position.

_________________________________
Applicant Name & signature Date: _____________________

PEOPLE MANAGEMENT, OFFICE AND SECURITY SERVICES USE ONLY

This Health Declaration Form has been reviewed and:

☐ No Medical Examination is required
☐ A Medical Examination is required

Name and Position of Reviewing Officer: ______________________________

Signature of Reviewing Officer: ____________________________ Date: _____________

Licensure No.: ______________________

Delegate approval if Medical Examination is recommended:

☐ No Medical Examination

☐ A Medical Examination is required by GBRMPA’s health service provider

Name and Position of Delegate: ___________________________________

Signature of Delegate: ___________________________________ Date: ______________