PPMForm - Telstra

Requestor Name:

Contact No:

Email Address:

Business Unit Name:

Employing Business Unit Name:

Employing Busines Cost Centre:

Purchase Order Number:

NB: The Business Unit Cost Centre or Purchase Order Number must be provided.

First Name:

Family Name:

Date Of Birth:

Job Requisition Number:

Phone No:

Mobile Phone No:

At least one phone number is required

Email Address:

Street Address:

Town/Suburb:

State:

Position Applied For:

Worksite:

Service:

Musculoskeletal / Functional Assessment (Doctor)

Drug & Alcohol Test (Australian Standards)

Driving vehicles

Working in pits & manholes

Working in cabel chambers & tunnels

Working in sub-floor & roof spaces

Cable jointing

Exposure to noise (where hearing protection needs to be worn)

Exposure to Radio Frequency Electromagnetic Energy

Digging

Using laptops

Dusty environment & wearing dust masks

Work requiring the routine wearing of non-disposable respirators

Climbing ladders

Using elevated work platforms

Climbing, working on towers/structures at height

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

Day 1:

To

Day 2:

To

Day 3:

To

Day 4:

To

Day 5:

To

Day 6:

To

Day 7:

To

Day 8:

To

Day 9:

To

Preferred Location:

Alternative Location:

Additional Notes:

Telstra Pre-Placement Medical Request Form

Requestor Details

Invoicing

Candidate Details

Type Of Service Required

Optional Services

What type of work activity is required for this job?

Candidate Availability