Melbourne Water Medical Request Form
All sections must be completed for appointments to be processed.
Requestor Details
Requestor Name:
Contact No:
Email Address:
Participant Details
First Name:
Family Name:
Mobile Phone No:
Alternative Phone No:
Email Address:
Current Position Held or Applied For:
Worksite:
Corporate / 990
Operations: Service Delivery: Regional Services: North West
Operations: Service Delivery: Regional Services: South East
Operations: Service Delivery: Regional Services: West
Operations: Service Delivery: Water Supply: Peninsula
Operations: Service Delivery: Water Supply: Preston
Operations: Service Delivery: Water Supply: Silvan
Operations: Service Delivery: Water Supply: Surrey Hills
Operations: Service Delivery: Water Supply: Tarago
Operations: Service Delivery: Water Supply: Winneke
Operations: Service Delivery: Wholesale Services: Brooklyn Pumping Station / Sewerage Transfer
Operations: Service Delivery: Wholesale Services: ETP - Eastern Treatment Plant
Operations: Service Delivery: Wholesale Services: WTP - Western Treatment Plant
Operations: Service Delivery: WLD: Brooklyn / West
Operations: Service Delivery: WLD: Healesville
Operations: Service Delivery: WLD: NERO - North East Regional Office (Croydon South)
Operations: Service Delivery: WLD: Olinda
Operations: Service Delivery: WLD: SERO - South Eastern Regional Office (Bangholme)
Operations: Service Delivery: WLD: Thomson Reservoir
Operations: Service Delivery: WLD: Wallaby Creek
Operations: Service Delivery: WLD: Warburton
Service Details
Medical Required:
Immunisations/vaccinations
Online Pre-Employment Medical
Pre-Employment Medical with Audio, Spiro & MS Ax
Pre-Employment Medical with Audio, Spiro, MS Ax & DAS
Routine Medical with Audio & Spiro
ADT (Diptheria and Tetanus)
Boostrix (Diphtheria, Tetanus, and Pertussis
Hepatitis A
Hepatitis A & B (Twinrix)
Hepatitis B
Influenza (quadrivalent)
MMR (Measles, Mumps, and Rubella)
Polio (IPOL) Booster vaccination
Q Fever
Varicella (Chicken Pox)
Typhoid
If you wish to book a medical that deviates from the above services you
MUST
contact an Injurynet PEM Program Coordinator first on (03) 9500 9968.
Additional Routine Medical Requirements
Services:
Chlorine Medical
Confined Space Medical
Firefighting Classification
Do you require Fire Fighting Classification?
Yes
No
Fire Fighting Classification:
A (Rappel / Hover Exit)
B (Arduous)
C (General)
E (Field Support)
F (Plant Operator)
G (Airborne)
H (Office Support)
Additional Notes: