Manager and Worksite Details

Requesting Manager's First Name *

Requesting Manager's Last Name *

Requesting Manager's Phone Number *

Requesting Manager's Email *

Worksite

Responsibility Cost Centre *

Participant Details

Participant First Name *

Participant Last Name *

Date of Birth

Participant Mobile Number *

Participant Email *

job Title

Preferred Location (Provide suburb & postcode)

Alternate Location (Provide suburb & postcode)

Available Day - First Preference

Time available from:

Time available to:

Available Day - Second Preference

Time available from -Second Preference:

Time available to - Second Preference

Available Day - Third Preference

Time available from - Third Preference:

Time available to - Third Preference

Service Required

Medical Required *

Office Based - Urine drug screen only (new employee or returnee) - no firefighting duties or IMT supportNew Employee Fire Fighter Assessment - Pre-employment medical, audiometry, spirometry & urine drug screenNew Employee - Fire Tower Operator - Pre-employment medical, audiometry & urine drug screenReturn Employee - Fire Fighter Assessment - Pre-employment medical, audiometry, spirometry & urine drug screenCurrent Employee - Fire Fighter Assessment - Pre-employment or Review medical, audiometry & spirometry Current Employee - Fire Tower Operator - Pre-employment or Review medical & audiometry

Notes:

Please note:

If you wish to book a medical that differs from the above services, please contact an Injurynet Program Coordinator first on 1300 307 418 or via email ppm@injurynet.com.au
Confirmatory testing on non-negative drug screens can delay PEM results by 2-5 days
Cancellations, reschedules and non-attendances will incur a fee

Privacy

Injurynet collects and uses personal and health information about your candidates / employees for the purposes of providing medical assessment services for your organisation. In making this medical assessment request, you are confirming that the candidate or employee has agreed to their personal information being disclosed to us. If you would like more information about how we manage, collect, hold, use and disclose personal information, please refer to our Privacy Statement.

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