Pre-Employment Questionnaire

Role Applied For *

Personal Information

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Date of Birth

USI Number

Do you need assistance with reading or writing?

Yes
No

Please Specify

Education & Training

Your background and industry experience.

Please provide a brief description of any mining/equipment expereince.

Do you hold a valid Australian Drivers License?

Yes
No

Please Upload the Front and Back of Your Drivers License.

Click or drag files to this area to upload. You can upload up to 2 files.

Trade Qualification

Certificate of Proficiency
Other Qualification
N/A

Please Specify the Trade Name on COP/Document *

Do you hold any of the following:

Recommended: Upload Your Licenses and Certificates Ticked Above

Click or drag files to this area to upload. You can upload up to 15 files.

For licences and cards please upload the front and back of the card.

Do you hold a Valid Order 43 Medical that has been completed within the last 12 months?

Yes
No
Not Sure

Approximate Date:

Have you completed a chest X-Ray in the past 12 months?

Yes
No
Not Sure

Approximate Date:

Do you have a copy of your valid Medical?

Yes
No
Not Sure

If yes - Please email your medical to [email protected]

Do you have Mine Site Experience?

0 - 1 Year
1 - 3 Years
3+ Years
No

Do you hold any of the following Inductions:

Other inductions held (within 3 years)

Salary Expectations (Hourly Rate)

What is your notice period with your current employer?

Right to Work In Australia

Titan Group is required under the Migration Act 1958 to ensure that any person applying for work has a legal right to work in Australia. Any person that is an Australia or New Zealand citizen or Permanent Resident of Australia will be required to produce primary and secondary identification to Titan Group which will provide their right to work. Any person that is not an Australia or New Zealand citizen or Permanent Resident of Australia will be required to produce their passport identification. Titan Group is required to check their Right to Work status with the Department of Immigration and Boarder Protection. NOTE: Any person has the right to refuse to cooperate with this check, however Titan Group would be unable to employ that person until their work entitlements can be verified.

Are you an Australian or New Zealand Citizen?

Yes
No

Please be advised you will be required to provide your birth certificate, passport or Visa if you progress in our recruitment process.

Do you have the right to work in Australia?

Yes
No

Visa Status

Employee Authority

Authority to check Right to Work Status
Titan Group would like your consent for Titan Group or one of its related entities undertaking a Visa Entitlements Verification Online (VEVO) Search with the Department of Immigration and Boarder Protection. We would like your consent for the Department to release your Right to Work Status to Titan Group and its related entities. By providing this authority, you understand that the information obtained from the Department will be used by Titan Group or its related entities for the purpose of establishing your legal right to work in Australia.

Do you consent Titan Group to enquire and confirm your Right to Work Status?

Yes
No
Third Choice

Reference Check Consent

Titan Group would like permission to contact your references, whether provided during your interview or in your resume, prior to your details being submitted to site for employment

Do you consent to Titan Group contacting your references?

Yes
No

Authority to Check Qualifications

Titan Group would like permission to enquire and confirm details of previously provided qualifications with relevant institutions and/or professional bodies as required

Do you consent to your qualifications being checked and confirmed by Titan Group?

Yes
No

Authority to Release Medical Information

In order to determine your fitness to perform the required duties, any reasonable steps that need to be taken to accommodate any disability you may have and whether you can safely perform the required duties, you consent to the following:
1. Coal Mines Insurance Pty Ltd and any applicable Work Cover Authority may provide information relevant to the above matters (including my workers compensation history) to and discuss the details of that information with Titan Group and its related entities; and
2. Titan Group and its related entities may collect information relevant to the above matters (including my workers compensation history) from Coal Mines Insurance Pty Ltd and any relevant Work Cover Authority within Australia.
3. Titan Group and its related entities may collect all relevant medical information, including pre-employment medical results as well as any information about my work-related injury / illness to assist with my rehabilitation and return to work from any medical practitioner and/or occupational rehabilitation provider as well as share this information to any representatives of my employer including client representatives.

You understand that with out the above consent to the disclosure of information, Titan Group and its related entities may not have sufficient information on which to decide to employ you.

Do you consent Titan Group to receive your Medical Information?

Yes
No

Medical Questionnaire

Please answer the following questions regarding your current Medical Status and Medical History in relation to the role you have applied for with Titan Group.

Please tick any that apply

Are you currently being treated by a Doctor?
Are you taking any medication?
Have you been hospitalised for any illness, had time off or had an operation in the last 3 years?
Have you ever had a sporting injury?
Are you required to wear glasses/contact lenses for work?
Have you or a previous employee ever lodged a Workers Compensation Claim?
Have you ever had a positive Drug & Alcohol Test?
Is there any reason why you cannot wear Personal Protective Equipment (PPE)?

Do you have or ever had any of the following conditions?

If you answered yes to any of the above, please provide details below

Please include names of any medication as these may be flagged on a pre-placement medical.

If you have any questions please add these below.

Name of Applicant Signing this Agreement. *