VETsurvey

Pre App Medical Form
MEDICAL DETAILS Please note: any information given will not affect your chances of securing a place in the MPA Skills Pre Apprenticeship Program. We ask for medical information so we can assist and cater to your needs to the best of our ability
Given Names: *
Surname: *
Date:	Invalid
Course Name: *
Location: *

1. Are you receiving medical treatment for an illness, injury or medical condition? If Yes, please explain in comments. *

1. Comments

2. Do you have any pre-existing/chronic/long term injuries or illness? If Yes, please explain in the comments: *

2. Comments

3. Have you been hospitalised and/or had any operations? If Yes, please explain in the comments: *

3. Comments

4. Are you taking any medications that may impact on your ability to work? If YES, please explain in the comments *

4. Comments

5. Do you currently have any allergies? If YES, please explain in the comments *

5. Comments

6. Criminal History Do you have any previous or pending criminal convictions or charges? If YES, please email through your Police Clearance to preapps@mpaskills.com.au *

Testimonial

Privacy Statement MPA Skills is bound by the Privacy Amendment (Private Sector) Act 2000 and is committed to safeguarding personal information it may hold at any time in respect of any individual in accordance with the requirements of those Principles. A copy of our Privacy Policy is available on request. Any personal information that we do collect, we keep strictly confidential and it can only be accessed by authorised staff within MPA Skills. MPA Skills keeps, maintains and uses personal information in accordance with the Privacy Amendment (Private Sector) Act 2000. Important Notice Section 79 of the Workers’ Compensation and Injury Management Act 1981 in Western Australia gives the Workers’ Compensation Dispute Resolution Body 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 him/herself as not having previously suffered from the disability, which is the subject of the claim for compensation. Declaration I solemnly declare that each and every answer above is true to the best of my knowledge and belief. I understand that any false or misleading information may result in termination of employment. If you are under 18 please ask your parent/guardian to sign. Declaration I solemnly declare that each and every answer above is true to the best of my knowledge and belief. I understand that any false or misleading information may result in termination of employment. Please tick the box and sign. If you are under 18, ask her parent/guardian to sign.

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