Registration

Please be aware that QRS Group request medical information to assisst in providing a safe working environment for all of our employees. These details are not for the purpose of determining the success or otherwise of any application for employment.

	Yes	No
Lung or breathing problems e.g. bronchitis, asthmas
High Blood Pressure
Epilepsy/Seizure
Broken Bones
Back/Neck Problems
Muscular or joint pain
Hernia
Heart/Chest pain
Arthritis
Sporting/Motor vehicle injuries
Faints, fits/convulsions
Frequent headaches
Eye or vision, Ear or hearing problems
Stroke
Cancer
Bleeding problems (abnormal)
Have you ever had to claim Workers Compensation?
Do you have a current Workers Compensation claim?
Have you ever had an accident/injury that has/could affect your employment
Have you ever had an industrial/work related accident?
Have you had time off in the last year due to any illness/injury?
Have you had any surgical operation in the last year?
Do you wear glasses or contact lenses?
Is there any reason you cannot wear personal protective equipment?
Have you suffered from RSI or Overuse Syndromes?
Have you worked in dusty or noisy conditions?
Have you ever worked with asbestos or chemicals
Have you experienced difficulty working in confined spaces

	Yes	No
Running up to 100 metres
Walking on rough ground
Kneeling
Standing for 2 hours
Sitting for 2 hours
Turning your head rapidly
Concentrating on a task
Hearing a normal conversation
Climbing a ladder or stairs
Using hand tools
Lifting or bending
Gripping firmly with both hands
Reading ordinary print
Repetitive movement of hands/arms
Crouching
Understanding English

Leave blank if you do not have a doctor.

IMPORTANT NOTICE – WORKERS COMPENSATION “Section 79 of the Workers Compensation and Assistance Act (1981) gives the Workers compensation Board discretion to refuse to award compensation, which would otherwise be payable, where it is proved that the worker has, at the time of seeking or entering employment, wilfully and falsely represented themselves as not having previously suffered from the disability, the subject of the claim for Workers Compensation”.

	Yes	No
Cadia Valley/Ridgeway
Cowal Gold Mine
North Parkes Mine
Australian Paper MIll, Maryvale
Visy pulp & Paper Tumut

	Yes	No
Confined Space Sentry
- Mines Experience
- Power Experience
- Paper Mill Experience

	Yes	No
Boiler Maker
- Arc-Air Gouging
- Mine experience
- Pipe work
- Plasma Cutting

	Yes	No
Fitter/Mechanic
- Light Vehicles
- Mine experience
- Pumps

	Yes	No
Crane Operator
- Bridge/Gant (CB)
- Slew 100T+ (CO)
- Slew 60T (C6)
- Slew 100T (C1)
- Mines Experience

	Yes	No
Rigger
- Basic
- Intermediate
- Advanced
- Mine Experience

	Yes	No
Dogger
- Mine Experience

	Yes	No
Fork Lift Operator
- Warehouse Experience
- Mines Experience

	Yes	No
Scaffolding
- Basic
- Intermediate
- Advanced

	Strongly Agree	Agree	Disagree	Strongly Disagree
Easy to use
Easy to understand
Form works without issue

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Personal Details

Emergency Contact/Next of Kin

Work Deatils

Work Entitlements

Medical History

In case of a work-related injury, who is your doctor

Referees

Second referee (optional)

Work History

Previous Job (optional)

Mine Inductions

Trade & Skills

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