Pre-Existing Injury Declaration

pre-existing injury declaration form

If you are the preferred applicant for this job you are required to disclose any (all) pre-existing injuries or diseases suffered by you of which you could reasonably be expected to foresee could be affected by you undertaking this job (Section 41[1] Workplace Injury Rehabilitation and Compensation Act 2013).

If you fail to disclose this information or if you provide false or misleading information you may not be entitled to WorkCover benefits in the event of any recurrence aggravation, acceleration, exacerbation or deterioration of a preexisting injury or disease, arising out of, or in the course, or due to the nature of this employment with The Angry Dog.

Where you have a pre-existing injury or disease The Angry Dog will consult with you regarding reasonable support and work modifications.

Employee Declaration

The following declaration is made for the purposes of sections 41(1) and (2) of the Workplace Injury Rehabilitation and Compensation Act 2013.

I have read and understood this form, including the information above.

I acknowledge that I am required to disclose all pre-existing injuries or diseases, which I could reasonably be expected to foresee could be affected by the nature of the proposed job.

Declaration

I do not believe that any injury or disease that I have is likely to be affected by the key activities required to be undertaken which impact on health and safety as listed above.

I have suffered the following injuries and/or diseases that may be affected by the duties described above.

Please specify:

Please select both the following

I acknowledge that any non-disclosure or false or misleading information on my part may result in section 41(2) of the Workplace Injury Rehabilitation and Compensation Act 2013 being applied. This reads “… if this sub-section applies, any recurrence, aggravation, acceleration, exacerbation or deterioration of any preexisting injury or disease arising out of or in the course of or due to the nature of employment with the employer does not entitle the worker to compensation under this Act.”

To the best of my knowledge the information provided in this Declaration is true and correct.

Name

First Name

Last Name

Job Title

Date

MM

DD

YYYY