Health & police check declaration

Health & police check declaration

This form is a prerequisite for attending an interview with 11 recruitment. Please complete it in full to ensure we don't place you in a position that may put your health and safety at risk.
Do you suffer from any condition/illness that may hinder your ability to perform any type of work?
Yes
No
Do you have a current workers' compensation claim?
Yes
No
Have you ever been injured at work?
Yes
No
If you answered "yes" to any of the above, please provide information below. Include specific details such as dates, type of injur /illness, current medication, etc.
Do you have any other health issues we should be aware of?
Have you ever been injured at work?
Yes
No
Have you ever been convicted of an offence?
Yes
No
Are you aware of any pending prosecutions?
Yes
No
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