PPMForm - COMPANY

Boral Driver Medical Service Request Form

All sections must be completed for appointments to be processed.

Requestor Details

Requesting Manager:

Contact No:

Email Address:

Employee Details

First Name:

Family Name:

Date Of Birth:

Mobile Phone No:

Alternate Phone No:

At least one phone number is required

Email Address:

Job Description:

Worksite

Worksite:

GL Code:

PO Number:

Service Details

Service:

(For Field Testing Officers and Bunzl Safety Testing / Manufacturing Positions only)

Worker Availability

Do you know when the Worker is available to attend a medical?

Injurynet will contact the Worker to obtain their availability and location for the medical.

Please select at least 9 hours over a minimum of 2 weekdays. If you would like to add additional days to your selection please click on +.

Injurynet will book the worker's medical based on the date and times you have provided. Please note, all cancellations and non-attendances will incur a fee.

Day 1:

Day 2:

Day 3:

Day 4:

Day 5:

Day 6:

Day 7:

Day 8:

Day 9:

Preferred Location:

Alternative Location: