psychological Consent Form Need help completing?1300 647 789 Step 1 of 4 25% 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*Date* DD slash MM slash YYYY Medical Questionnaire Name* First Last Date of Birth* DD slash MM slash YYYY Sex* Male Female Intersex / Other Email* Phone Number*Employment History: [Please document all previous employment history in tabs below]Job PerformedHours & days / weekLength 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:EmailThis field is for validation purposes and should be left unchanged.
