Enriched Health Care Pre-Employment Questionnaire

  • Date Format: DD slash MM slash YYYY
  • Please attach a photo of valid identification.
    0=No Pain 10=Extreme Pain
  • *If you have never experienced any of the conditions above, please indicate here (Please tick) 

    Please indicate if you have known family history for any of the above conditions:

  • If you have never experienced any of the conditions above, please indicate here. Additionally, please indicate if you have known family history for any of the above conditions.
    If yes, please provide details on quantity and frequency
    If yes, please provide details on quantity and frequency
    If yes, please provide details on quantity and frequency
    If yes, please provide details below:
  • COVID-19

  • For your safety as well as that of the community, the following question group is designed to assess your risk regarding COVID-19. Please note that COVID-19 is the specific name of the current coronavirus pandemic, due to the existence of multiple forms of coronavirus, the following question set will refer to it as COVID-19

  • Social Distancing & Hygiene

    Please confirm that you are practising the following social distancing rules.

  • Date Format: MM slash DD slash YYYY
  • DISCLOSURE

    The information collected on this application form is collected for the purpose of assessing your application for employment in the position for which you have applied or for another equivalent position for which you may have the skills and capabilities. It will form part of your employee record should you be successful.

    If any information sought is not provided your application may not be processed or assessed.

    Our Privacy Statement is available by contacting Enriched Heath Care or visiting Enriched Health Care’s Website (www.enrichedhealthcare.com.au). If you have any enquiries about privacy, you can contact our Health Care Services Manager via email workplace@enrichedhealthcare.com.au

  • CONSENT & DECLARATION

    I acknowledge and agree that the information provided by me in this form and any other information that I may subsequently provide may be disclosed to: 

    • Any entity involved in any restructure or transfer of Enriched Heath Care;
    • Enriched Pty Ltd and any related bodies corporate of Enriched Heath Care; or
    • Only those employees, agents or contractors or other service providers of Enriched Heath Care who reasonably require access to the information upon which I have signed a medical authority to release

     For the purpose of enabling Enriched Health Care to assess my application for employment in the position for which I have applied or for another position for which Enriched Health Care considers I may have the skills and capabilities.

    By Signing below, you consent to participate in assessments administered by Enriched Health Care staff and consent for Enriched Health to share medical or other information with your potential employer, other contacts and health care providers where relevant?