Employee Questionnaire

The purpose for completing this questionnaire is to allow us to identify any possible increased risks to your health or safety that could occur at this workplace. It is also an opportunity to identify your needs from our workplace. All information supplied will be kept confidential.

PART ONE
First Name *
First Name
If you use an English name instead of your traditional name, please enter it here.
Phone Number *
Phone Number
Please enter your Australian mobile number
Address *
Address
Please enter your Australian address
Have you been asked to submit this application by another person? *
How much work would you prefer *
Do you have access to transport to get you to the work location? *
When would you be available to start? *
When would you be available to start?
If Applicable when would you be required to stop working? (Visa expiry date)
If Applicable when would you be required to stop working? (Visa expiry date)
Are you an Australian Citizen? *
PART TWO
Do you have any infectious diseases that could be transmitted in a workplace accident? *
Eg. Hepatitis, Aids etc.
Do you give permission for Koala Farms to contact your previous employers / references? * *
Which departments of the our business would you be interested in working in? * *
Please select all that apply.
DECLARATION OF PRE-EXISTING INJURIES, MEDICAL OR MENTAL CONDITIONS
Required physical capabilities for the position Typical work includes planting, cutting and packing various varieties of lettuce and other vegetables. Work can involve long hours of moderate physical labour outdoors in various weather conditions. The role would require, among other things, for you to undertake: Repetitive manual lifting, repetitive bending twisting and kneeling, walking on slippery and uneven surfaces, standing for long periods, working outside for long periods, being exposed to a variety of weather conditions for long periods, operating and working around farm-related vehicles, plant, machinery and equipment; and effectively communicate to other people on the phone and in person. Do you understand the Required physical capabilities for the position?
The purpose of this declaration is to ensure that you are fully able to perform the inherent requirements of the role (with reasonable adjustments if required and approved by the prospective employer) and that you are not placed in an environment or given tasks that would result in risks to your safety or the safety of others. Under section 571B of the Workers Compensation and Rehabilitation Act 2003, you must disclose to your prospective employer any pre-existing injury or medical condition. A pre-existing injury or medical condition means an injury or medical condition existing during the employment process that you suspect, or ought reasonably to suspect, would be aggravated by performing the duties the subject of the proposed employment. Do you understand the purpose of this declaration.?
If you: Have a pre-existing injury or medical condition, knowingly make a false or misleading disclosure, under section 571C of the Workers Compensation and Rehabilitation Act 2003, in relation to the injury or medical condition; and you are employed under the employment process, you or any other claimant (eg your dependents) will not be entitled to compensation or to seek damages for any event that aggravates the pre-existing injury or medical condition. We will rely on any false or misleading disclosure as grounds for denying compensation and damages. If you give any incorrect or misleading answers or you omit to disclose relevant information to us, you may be: Ineligible for employment; or if employed, liable for discipline up to and including, dismissal. We endeavour to treat confidentially all details provided on this form. If you gain employment with us, the prospective employer, this document will be retained on your personnel file. If you do not gain employment with us, we will endeavour to promptly and securely destroy the information. Do you understand Your disclosure responsibility?
Before completing this declaration below, please read the required physical capabilities for the position and this document and contact us if you have any queries about the role or its requirements.
Please Tick all boxes
E.g. allergies, asthma, epilepsy, back or knee problems, colour blindness, etc.
To the best of my knowledge, the information provided in this declaration is true and correct * *
PART FOUR
Speak now or forever hold your peace...