Roundwood Worker Registration Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: 0000000000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth:

Date

Unique Student Identifier (USI number)

Citizen / Visa Status

Do you identity as Aboriginal or Torres Strait Islander?

Australian citizens, please upload your Passport or Birth Certificate below. Visa holders, please upload your Passport and Visa grant notification below.

What role(s) are you applying for?

Rows	YES	NO
General Labourer
Skilled Labourer
Formworker
Carpenter
Concreter
Steelfixer
Excavator Operator
Loader Operator
Dump Truck Operator
Roller Operator
Compactor Operator
Dozer Operator
EWP Operator
Forklift Operator
Mobile Crane Operator
Electrical Spotter
Dogman/Rigger
Traffic Controller
Other

What role(s) are you applying for?

If other, please provide details below:

What current tickets/licenses do you hold:

Rows	YES	NO
White Card
Drivers License
Working at Heights
EWP under 11m
EWP over 11m
HR License
Roller Operator Ticket
Rail Industry Worker (RIW) card
Forklift Operator License
Mobile Crane Operator License
Electrical Spotter Ticket
Dogman/Rigger Ticket
Excavator Operator License
Front End Loader Operator License
Moxy / Dump Truck / Articulated Haul Truck License
Compactor / Bobcat License
Traffic Controller Ticket
Other

Do you hold a Working With Children's License?

Rows	Yes	No
Working With Children's License - VIC
Working With Children's License - NSW
Working With Children's License - QLD

What current/tickets licenses do you hold?

If other, please provide details below:

Please upload images of your Drivers License, White Card, plus FRONT & BACK of all tickets/licenses you currently hold below:

Please upload a recent profile picture/selfie below:

Please upload your CV/Resume here:

Screenshot image is fine, if PDF or Word.doc isn't available.

Do you have a car?

What shirt size are you?

Emergency Contact Name

Emergency Contact Number

1. Have you been involved in any motor vehicle accidents resulting in personal injury?

If yes, please give details of motor vehicle accidents or Third Party claims relating to injuries sustained:

2. Have you ever lodged a claim for workers compensation?

If Yes, please give details including date, injury and employer at the time of claim:

3. Have you suffered back pain or strain injury (including back surgery)?

If yes, please give details:

4. Have you suffered from shoulder, neck or arm pain or strain?

If yes, please give details: Yes/ No

5. Have you suffered from hip, knee or ankle pain?

If yes, please give details:

6. Have you had a full medical clearance for any injury identified in questions 1 to 5 ?

Please provide details:

7. Are you receiving any ongoing treatment for injuries identified in questions 1 to 5?

Please provide details:

Do you suffer from any medical condition (including physical, psychiatric, psychological) for which you are receiving treatment?

Have you ever had or do you have, any of the following?

Rows	Yes	No
Lower back, neck or thoracic spinal pain
Sciatica
Wrist or elbow pain or weakness
Tenosynovitis, carpel tunnel or RSI?
Arthritis, rheumatism or painful joints or other musculoskeletal pain
Any broken bones or torn cartilage
Hernia
Diabetes
Epilepsy, dizzy/giddy/fainting spells, blackouts or neurological disorder
Mental health condition including severe anxiety and depression
High blood pressure, chest pain or heart or circulatory trouble
Asthma, chronic bronchitis or other chest problems
Auto Immune Disease or on immunosuppressant medication
Nail infections, or chronic skin infections
Eczema, dermatitis, hives or other skin rashes or complaints
Have you ever been diagnosed with latex allergy
Allergic or adverse reaction to any medicines, vaccinations, insect bites, animal fur, band aids, rubber and/or foods
Any problems with vision or hearing
Any other serious illness
Current health problems, illness or injury related to any previous employment

If you answered YES to any of the above conditions, please give details (e.g. year, diagnosis, treatment, medication etc)

Have you been exposed to or monitored for any of the following?

Rows	YES	NO
Cytotoxics
Glutaraldehyde
Ethylene oxide
Asbestos
Pesticides
Lead
Solvents
Excessive noise or required to wear hearing protection
Have you had previous hearing testing
Have you had previous health screening / medicals for exposure to asbestos or work-related dust

If you answered YES to any of the above, please give details (e.g. year and place)

I hereby declare that the above statements and answers are true and correct to the best of my knowledge.

Signature

Date

Roundwood Worker Registration Form

Medical Questionnaire