psychological Consent Form

Step 1 of 4

Name
This field is for validation purposes and should be left unchanged.
Consent Form*
1) I give permission for the assessor to conduct a pre-employment assessment, in order to determine and document my capability demonstrated at the time.

2) I am aware that I will not be required to perform any activities / assessments that I do not feel comfortable performing. If I choose to not perform a task, the reason
provided will be documented in the reporting of results.

3) I am aware that during the assessment, I may cease performing a required task should I feel incapable of completing such and/or concerned of my health and safety. Noting this may impact the overall assessment outcome.

4) I am aware that the pre-employment tasks may be ceased at the discretion of the assessor at any stage, should the task be deemed unsafe.

5) I am aware that I should advise Recovery Partners should I experience any difficulties with the pre-employment tasks.

6) I declare that all the information provided in the medical consent form and during the performance of the assessment is an accurate representation of my medical history and capability at the time.

7) I give permission for the assessor to release information to Recovery Partners and the
employer regarding the results of the assessment.

8) I agree that providing an electronic signature is a sufficient means to indicate my
understanding of the pre-employment assessment, and that I have provided an accurate
representation of my medical background / capacity to the best of my knowledge.

I agree to undertake a pre-employment examination with recovery partners. The examination will include psychometric screening tool completions and a clinical interview with a consultant.

I agree to the information contained in this document being used to determine my current health status and personal safety requirements and my ability to perform the role for which I am being assessed. The answers given to the below questions are true and correct to the best of my knowledge.

By signing, I acknowledge that I have read and agree to the above, and therefore give consent to all terms.

Signature*
Your Name
Your Name
Your Name
Date*

Medical Questionnaire
Name*
First Last
Date of Birth*

Sex*

Male

Female

Intersex / Other
Email*

Phone Number*
Employment History: [Please document all previous employment history in tabs below]
Job Performed Hours & days / week Length of Employment

Medical History
Cardiovascular
Have you had any diagnosed cardiovascular conditions in the past that have been resolved [i.e. including and not subject to high blood pressure, heart problems, stroke, peripheral disease].*

Yes

No
Are you currently diagnosed with any cardiovascular conditions [i.e. including and not subject to high blood pressure, heart problems, stroke].*

Yes

No
Has any member of your family [mother, father, brother, sister] had a heart attack or stroke before the age of 55 years*

Yes

No
If yes, please describe including the treatment plan [i.e. medications]:
Endocrinological
Have you been diagnosed with any endocrinological condition [i.e. including and not subject to hyper-thyroid, hypo-thyroid, type 1 diabetes].*

Yes

No
If yes, please describe including the treatment plan [i.e. medications]:
Neurological
Have you had any diagnosed neurological conditions in the past that have been resolved [i.e. including and not subject to epilepsy, multiple sclerosis, cerebral palsy, Alzheimer’s].*

Yes

No
Are you currently diagnosed with any neurological conditions [i.e. including and not subject to epilepsy, multiple sclerosis, cerebral palsy, Alzheimer’s].*

Yes

No
If yes, please describe including the treatment plan [i.e. medications]:
Psychological
Have you been diagnosed with any psychological condition[s] that have been resolved [i.e. including and not subject to depression, anxiety, post-traumatic stress disorder].*

Yes

No
Are you currently diagnosed with any psychological conditions [i.e. including and not subject to depression, anxiety, post-traumatic stress disorder].*

Yes

No
If yes, please describe the diagnosis, including any relevant precipitating factors and treatment plan [i.e. medications]:
Respiratory
Have you had any diagnosed respiratory condition in the past that have been resolved (i.e., including and not subject to asthma, chronic obstructive pulmonary disease)?*

Yes

No
Are you currently diagnosed with any respiratory conditions (i.e., including and not subject to asthma, chronic obstructive pulmonary disease)?*

Yes

No
If yes, please describe including the treatment plan (i.e., medications):

Please indicate if your vaccinations are up to date for:
Tetanus
Diptheria
Whooping Cough
Measles / Mumps
Chicken Pox
Hepatitis B
Fully Covid-19 Vaccinated
Do you consume alcohol on a frequent basis?*

Yes

No
If yes, how often do you consume alcohol?

Less than once per week

Once per week

Average 1-2 days per week

Average 3-4 days per week

Average 5-6 days
When you consume alcohol, how many standard drinks may you have?

1 - 2 standard drinks

3 - 4 standard drinks

5-8 standard drinks

>8 drinks
You will be taking part in a pre-employment assessment that will be cognitively and psychologically demanding. To the best of your knowledge do you have any medical condition(s) that may affect your ability to perform the assessments?*

Yes

No
To the best of your knowledge, do you have any medical condition(s) that may affect your ability to complete the applied for position as per the job task analysis?*

Yes

No
If yes to any of the above, please describe:

Team

Careers

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Job Task Analysis

On-Site Health Monitoring

EAP Service

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psychological Consent Form

Step 1 of 4

Medical Questionnaire

Medical History

Cardiovascular

Endocrinological

Neurological

Psychological

Respiratory