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Have you had an injury or medical condition caused by gradual process, disease
or infection, for example hearing loss, sensitivity to chemicals, repetitive strain
injuries that may be aggravated or further contributed to by the tasks of this job?
Please refer to the job description. (If yes, please detail)
Yes No
If yes, how might WDC reasonably accommodate this illness/disability/condition?
Have you ever suffered from prolonged backache, back injury or a slipped disc?
Yes No
Are you on any medication that could affect your health and safety, affect your
ability to carry out the work for which you have applied, or affect your ability to get
to/from work? (If yes, please detail)
Yes No
If yes, how might WDC reasonably accommodate this illness/disability/condition?
Have you made any ACC or workplace accident insurance claim for disability (in
the last 5 years) for a condition that might reoccur, or be aggravated by the work
for which you have applied?
Yes No
Do you consent to WDC requesting a report from the ACC, which will give a
history of up to 5 years of your ACC claims?
Yes No
If required do you consent to undergo a medical examination to assess your
fitness for the job to which you are applying?
Yes No
If applicable to your role do you consent to biological & health monitoring in
accordance with the Health and Safety in Employment Act 1992?
Yes No
If you are required to drive a company vehicle, do you suffer from any condition
that could affect, or restrict, your ability to hold a driving licence?
Yes No
In relation to the work, are there any special health/safety considerations you wish
to note or discuss? (If yes, please detail)
Yes No
If applicable to your role, do you suffer from any allergy or asthma?
Yes No
If applicable to your role, have you ever suffered from faints/fits, epilepsy,
blackouts or giddiness
Yes No
