New Wilkie Energy Medical Data & Declaration Form

This Information Form must be completed by the by the worker who's name appears on the below form.

For support with the registration or induction process, contact the Pegasus New Wilkie Compliance Team on 1300 365 747 or newwilkie@pegasus.net.au.

Worker Details

Workers Name*

First NameLast Name

Workers Date of Birth*

Date

Workers Email Address*

example@example.com

Workers Phone Number*

Company Administrators Name*

First NameLast Name

Company Administrators Email Address*

example@example.com

Do you have any medical conditions (e.g., diabetes, epilepsy, heart ailments, asthma)?*

YesNo

Please specify*

NOTE: Due to magnetic fields and/or intense light discharge, people with pacemakers and/or epilepsy may not enter places where welding is being conducted (unless written medical clearance has been obtained).

Do you have any allergies (e.g., penicillin, dust, chemicals)?*

YesNo

Please specify*

Have you ever suffered from any physical or psychological impairments (e.g., knee reconstruction, depression, hearing loss)?*

YesNo

Please specify*

Do you have any phobias (e.g., fear of heights)?*

YesNo

Please specify*

Are you required to take any medication?*

They are required to take medication as prescribed by their Doctor/SpecialistThey are taking over-the-counter medicationThey are not taking any medication

Please provide the generic brand names of the medication being taken*

Have you used this medication before?*

YesNo

Please list the potential side effects of the medication*

Type N/A is there are no side effects

Medical Declaration

I acknowledge that I have informed New Wilkie Energy Pty Ltd about any medications I am taking and/or physical restrictions that may impact upon their fitness for duty on this site.

I consent that a copy of this Medication declaration is provided to an approved NATA-accredited laboratory if required.

I acknowledge to the passing on of this medication declaration, provided by me for the purpose of declaring medications and their dosages, which I have been prescribed or that I am taking and that I registered on a drug screening.

I confirm that all information contained and/or declared in this document is true and correct to the best of my knowledge. I confirm that should any information on this form change prior to its expiration date (six months from today), I will submit a new form prior to re-entering the site.

I acknowledge

Date*

Date

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