WARNING: This document forms a part of your application for employment under the Police Act 1998 and/or the Protective Security Act 2007. Questions not correctly or fully answered, or the withholding of relevant information, may lead to prosecution for making a false statement pursuant to the provisions of Section 69 of the Police Act 1998 and/or Section 40 of the Protective Security Act 2007. A maximum penalty of $2,500 or six months imprisonment applies.
Cross Applicable – Applicant MUST provide an answer to ALL questions where check boxes are provided
APPLICANT DETAILS
Full Name:	Date of Birth:	/ /
Address:
Current Occupation:
Previous Occupation(s):
Sporting Activities:
Name and Address of your Family Doctor:
MEDICAL HISTORY
Have you ever had an accident or illness for which you have applied or intend to apply for compensation or pension of any type, or applied for sickness benefit?	YES NO
Has an accident or illness kept you off school or work for more than 14 days?	YES NO
Have you ever been rejected or deferred for life insurance or had a loading on your policy?	YES NO
Have you ever had any operations?	YES NO
Have you ever been diagnosed with a medical illness or physical injury?	YES NO
Have you ever been a patient in any type of hospital after infancy?	YES NO
Have you ever had to change a job or not undertake specific duties because of an adverse reaction to grease, dust, chemicals or other substances?	YES NO
Have you been immunised against Tetanus, Diphtheria, Whooping Cough, Polio, Hepatitis A, Hepatitis B, Varicella (chicken pox), COVID-19? If YES, please state which and year of vaccination:	YES NO
Medicare Card Number:	Individual Reference Number:
Have you ever had a positive Mantoux (Tuberculosis) skin test?	YES NO
Have you ever been treated with an organ transplant or prosthetic device (e.g. artificial hip) or implanted pump or electrical device?	YES NO
Do you currently have any medical condition or injury?	YES NO
Do you take any medication, prescription or other?	YES NO
If YES, please give details (name, dose & duration):
Please provide:	Height:	cm	Weight:	kg	BMI:
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication (if current) and resolution.
PERSONAL SOCIAL INFORMATION
Do you participate in any sport, physical activity or exercise program? If YES, provide details below.	YES NO
Activity or Sport:
How many times per week:
Average minutes per exercise per session:
Do you drink alcohol? If YES, provide details below.	YES NO
Number of standard drinks per week:
Have you ever smoked? If YES, provide details below.	YES NO
Number of years:
Number of cigarettes per day:
When did you stop smoking?
Do you use or have you experimented with any of the following?
Marijuana or other non-prescribed drugs	YES NO
Intravenous drugs	YES NO
If YES, please provide additional information for each type of illicit drug used:
Drug type:
Period of use:
How often:
Last time you used the drug:
Drug type:
Period of use:
How often:
Last time you used the drug:
CARDIOVASCULAR SYSTEM
Have you ever had or do you have any of the following symptoms or conditions?
Chest pain on exertion or angina	YES NO
Palpitations or irregular heartbeat	YES NO
High or low blood pressure	YES NO
Heart murmur or rheumatic fever	YES NO
Heart surgery	YES NO
Any investigations of the heart including ECG, stress ECG or ultrasound	YES NO
Any other heart disease	YES NO
Varicose veins	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
RESPIRATORY SYSTEM
Have you ever had or do you have any of the following symptoms or conditions?
Persistent or recurrent breathlessness	YES NO
Persistent or unusual cough	YES NO
Asthma or wheezing – past or present	YES NO
Use of an inhaler before or after exercise or with a “cold”	YES NO
RESPIRATORY SYSTEM (continued)
Bronchitis, pleurisy or pneumonia, or tuberculosis	YES NO
Pneumothorax or collapsed lung	YES NO
Sleep apnoea or sleep disorder	YES NO
Any other lung disease	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
ASTHMA QUESTIONNAIRE
Have you ever been admitted to hospital for asthma after the age of 15 years?	YES NO
Has any doctor or medical provider ever told you that you have asthma?	YES NO
In the past 12 months, how well did you feel your asthma was controlled? Not at all Partially controlled Well controlled Not Applicable (N/A)
In the past 12 months, did you miss any work, school or normal activity because of your asthma?	N/A YES NO
In the past 12 months, have you at any time taken medication (including inhalers) for your asthma?	N/A YES NO
In the past 12 months, were you woken at any time by your asthma during the night?	N/A YES NO
In the past 12 months, were you limited at any time in your activities because of your asthma?	N/A YES NO
In the past 12 months, did you experience shortness of breath at any time because of your asthma?	N/A YES NO
In the past 12 months, did you experience any wheezing at any time?	YES NO
Has your chest sounded wheezy at any time during or after exercise?	YES NO
Have you had an attack of shortness of breath that came on following strenuous activity? If you have responded YES to any of the above, an asthma management plan MUST be provided.	YES NO
GASTROINTESTINAL SYSTEM
Have you ever had or do you have any of the following symptoms or conditions?
Frequent indigestion, heartburn or recurrent abdominal pain	YES NO
Frequent nausea or vomiting	YES NO
Passing blood through the bowels	YES NO
Frequent diarrhoea or constipation	YES NO
Ulcer of the stomach or duodenum	YES NO
Gall bladder problems	YES NO
Hepatitis or other liver disease	YES NO
Irritable bowel syndrome	YES NO
Ulcerative colitis or Crohn’s disease	YES NO
Haemorrhoids (Piles)	YES NO
Hernia of any sort (e.g. umbilical, groin, stomach)	YES NO
Any surgery to the abdominal area	YES NO
Any special dietary needs	YES NO
Any other bowel or abdominal organ disease	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
GENITOURINARY SYSTEM (continued)
Have you ever had or do you have any of the following symptoms or conditions?
Blood in the urine	YES NO
Difficulty or pain passing urine	YES NO
Incontinence/urgency to urinate	YES NO
Kidney stones	YES NO
Kidney disease, infection or tumour	YES NO
Bladder disorder, infection or tumour	YES NO
Kidney, bladder or urinary tract surgery	YES NO
Sexually Transmitted Disease (STD)	YES NO
Bedwetting after the age of 10 years	YES NO
MALE ONLY:
Surgery to the testis or penis	YES NO
Swollen or painful testis	YES NO
FEMALE ONLY:
Menstrual problems such as irregular, absent, very painful or very heavy periods	YES NO
Cervical smear (pap smear) abnormality, cone biopsy or referral for laser therapy	YES NO
Endometriosis	YES NO
Chronic pelvis inflammatory disease	YES NO
Pregnancy	YES NO
Any other gynaecological problems not mentioned above including surgery	YES NO
Any history of breast lumps, breast surgery or breast pain	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
MUSCULOSKELETAL SYSTEM
Have you ever had or do you have any of the following symptoms or conditions?
Hip injury or pain	YES NO
Knee injury or pain	YES NO
Ankle injury or pain	YES NO
Foot injury or pain	YES NO
Lower limb pain especially on exercise (e.g. shin splints)	YES NO
Shoulder injury or pain	YES NO
Elbow or wrist injury or pain	YES NO
Neck injury or pain (including whiplash)	YES NO
Back injury or pain	YES NO
Sciatica	YES NO
Joint pain or arthritis anywhere in the body	YES NO
Pain to any part of your body during or after exercise (e.g. walking or running)	YES NO
Fractured, broken or cracked bones (including stress fractures)	YES NO
Dislocated or subluxated joints	YES NO
Loss of the use of any limb or digit	YES NO
Surgery to any joint, including reconstructive surgery	YES NO
Surgery to any limb, including internal fixation of fractures by plating or pinning	YES NO
Problems carrying a heavy load (equal to 25kg)	YES NO
Any other bone, joint, ligament, tendon or muscle problems	YES NO
MUSCULOSKELETAL SYSTEM (continued)
Any history of treatment by a physiotherapist, chiropractor or other therapist	YES NO
Do you wear orthotics or special footwear?	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
NEUROLOGICAL SYSTEM
Have you ever had or do you have any of the following symptoms or conditions?
Head injury	YES NO
Loss of consciousness	YES NO
If YES for how long? Hours:	Minutes:
Concussion	YES NO
Dizzy spells, fainting or blackouts	YES NO
Epilepsy, fits or convulsions	YES NO
Frequent or severe headaches	YES NO
Migraine	YES NO
Difficulty with concentration or memory	YES NO
Surgery to the head or nervous system	YES NO
Paralysis	YES NO
Any other neurological disease	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
ENDOCRINE AND METABOLIC SYSTEM
Have you ever had or do you have any of the following symptoms or conditions?
Diabetes abnormal blood sugar	YES NO
Thyroid disease or surgery	YES NO
Gout	YES NO
Any significant alteration in weight over the last 12 months	YES NO
Any other endocrine (hormonal) disease	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
EAR, NOSE AND THROAT
Have you ever had or do you have any of the following symptoms or conditions?
Recurrent or persistent ear infections	YES NO
Tinnitus or ringing in the ears	YES NO
Deafness or loss of hearing	YES NO
Perforated ear drum or surgery	YES NO
Difficulty hearing a conversation in a noisy room	YES NO
Motion sickness including travel sickness	YES NO
Vertigo or problems with balance	YES NO
Allergy, hayfever or allergic rhinitis	YES NO
Recurrent or persistent sinusitis	YES NO
EAR, NOSE AND THROAT (continued)
Throat problems or difficulty swallowing	YES NO
Any other ear, nose or throat problems including surgery	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
ORAL AND DENTAL
Have you ever had or do you have any of the following symptoms or conditions?
Inflammation or infection of the oral cavity including, HSV-1 (cold sores)	YES NO
Deformities or abnormalities of the mouth or jaw	YES NO
Disorder of voice or speech	YES NO
Current orthodontic or specialist dental treatment	YES NO
Any other oral or dental problems including any future specialist dental treatment requirements	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
EYES
Have you ever had or do you have any of the following symptoms or conditions?
Persistent or recurrent eye allergy or infection of the eye and/or eyelids	YES NO
Ever worn spectacles or contact lenses	YES NO
Loss of vision in either eye	YES NO
Colour perception problems, e.g. protan/deutan abnormality	YES NO
Glaucoma	YES NO
Any eye surgery including laser surgery	YES NO
Any other eye disease or injury	YES NO
Do you avoid, or experience difficulty when driving at night, dusk, dawn or when visibility is low?	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
SKIN
Have you ever had or do you have any of the following symptoms or conditions?
Any active skin disease or infection	YES NO
Skin reactions to occupational contact, chemicals or allergic reactions of any type	YES NO
Chronic skin disease such as urticarial, eczema, dermatitis or psoriasis	YES NO
Acne	YES NO
Pilonidal sinus	YES NO
Any treatment for skin cancers or for sun damaged skin	YES NO
Any other skin diseases or problems	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
BLOOD AND LYMPHATIC SYSTEM
Have you ever had or do you have any of the following symptoms or conditions?
Anaemia	YES NO
Blood disorder or bleeding or clotting problem (e.g. haemophilia, thalassaemia or haemochromatosis)	YES NO
Removal or malfunction of the spleen	YES NO
Any other blood or lymphatic system disease	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
INFECTION
Have you ever had or do you have any of the following symptoms or conditions?
Malaria or unexplained fevers	YES NO
Chronic parasitic infection or tropical disease	YES NO
Any significant infection requiring a prolonged period of convalescence such as:
Chronic fatigue syndrome	YES NO
Glandular fever	YES NO
Have you ever been diagnosed, tested positive or suspected of having any of the following?
HIV (AIDS) infection	YES NO
Hepatitis B infection	YES NO
Hepatitis C infection	YES NO
ALLERGY
Have you ever had an allergic reaction including life-threatening anaphylaxis to any of the following?
Medicine, drug or serum, including anaesthetic agents and vaccines	YES NO
Foods or additives (e.g. peanuts, gluten, lactose, MSG or seafood)	YES NO
Animals or insect bites (e.g. dogs, cats, spiders, bees etc.)	YES NO
Any other substances	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
MENTAL HEALTH AND TRAUMA
Have you ever had or do you have any of the following symptoms or conditions?
Any unusual stress in your work or home life	YES NO
Sleepwalking after the age of 14 years	YES NO
Bedwetting after the age of 10 years	YES NO
Panic attacks, hyperventilation or anxiety or phobia disorder	YES NO
History of drug or alcohol dependency	YES NO
Have you been diagnosed or received treatment for Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) or any other learning disorder or learning disability (including dyslexia)?	YES NO
If YES, have you ever been prescribed any medication to treat or modify those conditions, for example but not limited to, Ritalin, Dexamphetamine or Modafinil?	YES NO
During school, did you attend any special education/support programs, receive suspension or expulsion?	YES NO
Have you ever received treatment for Post Traumatic Stress Disorder (PTSD)?	YES NO
Have you ever had a suspected or diagnosed mood or affective disorder (e.g. depression, bipolar disorder)?	YES NO
Have you ever had a suspected or diagnosed anxiety disorder (e.g. panic disorder, anxiety, obsessive-compulsive disorder, eating disorder)?	YES NO
MENTAL HEALTH AND TRAUMA (continued)
Have you ever had a suspected or diagnosed psychotic disorder (e.g. hallucinations or delusions, psychosis, schizophrenia)?	YES NO
Have you ever been admitted to a hospital for treatment of a psychiatric, psychological or substance related condition?	YES NO
Have you ever been the victim of, or witness to, domestic violence as an adult or child?	YES NO
Have you ever attempted suicide or self harm?	YES NO
Have you ever consulted or sought treatment from any of the following?
Psychiatrist	YES NO
Psychologist	YES NO
Counsellor	YES NO
Social worker	YES NO
Have you ever witnessed the death of another person?	YES NO
Have you ever seen a deceased person?	YES NO
Have you ever been involved in the recovery, disposal or other handling of a deceased person?	YES NO
Have you ever been directly/indirectly involved in the cause of death of another person?	YES NO
Has any family member, friend or colleague ever been killed, unlawfully detained, assaulted or robbed?	YES NO
Other than any previous employment with SA Police, have you worked with or for military/police agencies?	YES NO
Have you ever lived or worked in an area subject to armed conflict, military operations, martial law, or the operation of peacekeeping forces?	YES NO
Have you ever been involved in or witnessed the assault, robbery, unlawful detention or torture of another person?	YES NO
Have you ever been the victim of, or witness to, a sexual assault?	YES NO
Have you been exposed to any other event(s) or experience(s) (not covered by previous questions) which had a traumatic effect on you?	YES NO
Have you ever experienced any other psychological or psychiatric conditions, disorders, or problems not outlined above?	YES NO
If YES to above mental health and trauma questions, please provide additional information including dates, treatments, medication and resolution.
CANCER AND/OR MALIGNANCY
Have you ever had or do you have any of the following symptoms or conditions?
Any type of cancer or tumour or unexplained lump	YES NO
Any malignant condition which is now in remission	YES NO
If you have responded YES to any of the above, please provide additional information including dates, treatments, medication and resolution.
SIGNIFICANT FAMILY HISTORY
Has any member of your immediate family been treated for, or suffered from, any of the following?
Blood disorder or bleeding or clotting problem (e.g. haemophilia, thalassaemia or haemochromatosis)	YES NO
Cancer	YES NO
Heart disease	YES NO
High blood pressure	YES NO
Diabetes	YES NO
Mental or emotional disorders (e.g. depression, anxiety, schizophrenia)	YES NO
Attempted suicide	YES NO
Tuberculosis	YES NO
SIGNIFICANT FAMILY HISTORY (continued)
Please provide further details or comments below:
(List any illnesses family members have experienced and state if deceased and cause of death, give age as at time of death)
RESIDENCY/SERVICE OUTSIDE OF AUSTRALIA
Have you ever resided or served outside of Australia? If YES, provide details of country, reason and dates:	YES NO
DEFENCE FORCE HISTORY
Have you ever previously applied to join any Defence Force?	YES NO
Have you ever previously served in any Defence Force?	YES NO
If YES to question 72, reason for rejection or discharge was: Unsuitable Medical Education Term Expired Psychological Unknown
OTHER INFORMATION
Give details of any accidents (including driving/motor vehicle accidents) or illnesses not referred to above. Include details of medical examinations, advice and/or treatments, x-rays, worker’s compensation claims, motor vehicle injury claims or veteran’s compensation claims. Give details of any other information that may be relevant.
DECLARATION
The information provided by me in this document is true and accurate to the best of my knowledge and belief. I acknowledge that questions not correctly or fully answered, or the withholding of relevant information, may lead to prosecution for making a false statement pursuant to the provisions of Section 69 of the Police Act 1998 and/or Section 40 of the Protective Security Act 2007, and that a maximum penalty of $2,500 or six months imprisonment applies. I authorise any Medical Practitioner or any other person who has treated me or whom I have consulted for any illness, injury or condition, whether physical or mental, to release to South Australia Police any information concerning my health in his or her knowledge or possession, including copies of any specialist or other reports.
I have read and acknowledge the above declaration
Applicant Name:	Date:	/ /
Applicant Signature: (to be signed later with police witness)	Date:	/ /
MEDICAL ASSESSMENT GUIDELINES FOR OPERATIONAL WORK
MEDICAL GUIDELINES
SAPOL medical standards state any recruit applicant with severe, intermittent, debilitating, acute or chronic medical conditions are generally considered unsuitable for recruitment. Each recruit applicant is assessed on an individual basis for suitability for operational work. SAPOL’s policy further requires each potential recruit with a history of any chronic condition to be assessed on an individual basis, in regard to the variability and severity of the chronic condition. SAPOL has determined that it is unacceptable to allow a police applicant, recruit, cadet, Police, or Protective Security Officer to be placed in a position where they may jeopardise their health by being unable to access urgent medical assistance. The working life of an operational officer is ruled by the adhoc situations and emergencies that unpredictably result from law enforcement. In determining fitness for duties, the individual is required to be alert and able to respond in all circumstances.
Recruit Training encompasses the following physical tasks, which need to be performed safely and effectively: –
Running (sprinting, endurance) at speed on uneven ground and varying terrain Marching on hard surfaces, roads and parade grounds Weight training Obstacle courses Climbing fences to maximum height of 2 metres Dragging a dead weight (20-30kg) a distance of 20-30 metres Crawling, jumping and negotiating obstacles Baton training, with twisting and lunging Defensive tactics - bending, twisting/being taken to the ground (on a mat), striking with hands and feet Restraint holds - muscle manipulation through active and passive ranges of wrist, elbow, shoulder, knee and ankle joints, within a static and dynamic ranges of movement Firearms shooting - over a 5 day course, standing for long periods, kneeling and lying prone; practical scenario exercises requiring working in confined spaces Handcuffing, both standing and after wrestling to the ground, including being handcuffed in these positions as a role player Body armour wearing (weighs 30kg) – static and moving around, running at times in armour, constantly wearing a 9kg gun belt. Driver training - 10 day course requiring sitting in motor vehicle for long periods, driving on dirt roads, high speed manoeuvring in wet and dry conditions, heavy braking and bracing around circuit.
All activities need to be performed wearing a fully equipped accoutrement belt up to 9kg in weight
Physical requirements of a SAPOL frontline officer include, but are not limited, to the following:
Adequate vision, corrected or uncorrected to 6/9, mild deutan acceptable, protan unacceptable Hearing 30 DB and less for speech discrimination at 750 KW – 4,000 KW acceptable Appropriate cognition, concentration, reality, mood and memory ability No medication likely to impair physical ability, appropriate mood or cognition Absence of any psychiatric disorder or substance dependency A body mass index (BMI) ideally less than 30, heavy musculature is taken into consideration Adequate cardiovascular ability, including ability to manage the standard for age exercise ECG testing, all applicants above the age of 35 will require an exercise ECG Run without warning, chasing over obstacles and uneven terrain Climb at a reasonable rate, including at least one flight of steps Ability to work safely at heights No significant injury to limbs, trunk or spine Ability to wear body armour, weighing up to 30kg Walk for extended periods Physically wrestle an offender during the course of an arrest or restraint Combative/offender work, including baton use Lift and carry an injured person Fit to drive, including alighting from a vehicle multiple times during a shift with accoutrement belt insitu, high speed and night driving Manage aggressive behaviour of offenders Arresting unwilling and uncooperative offenders Subduing and handcuffing offenders Placing unwilling persons into a police vehicle Custody management and enforcement Firearms use Work rotational shift work Irregular access to food, due to shift work and extended work hours Inability to always have ready access to a toilet
These activities should be assessed as occurring over a sustained period of time and not just in a single activity occurrence
Most tasks are expected to be completed wearing operational uniforms and a complete accoutrement belt up to 9kg in weight
For any further enquiries, please contact –	SA Police Recruiting T: (08) 7322 3353
SOUTH AUSTRALIA POLICE RECRUITMENT FITNESS AND AGILITY TEST CRITERIA
Requirements are reviewed regularly and may include but is not limited to the following- Applicants are to wear suitable clothing e.g. shorts, t-shirt, tracksuit pants, running shoes for the purpose of completing the fitness and agility tests - no jewellery is to be worn.
BODY FAT SKIN FOLD – Conducted by Medical Officer
Skin-callipers are used on 4 anatomical locations. The calculation process accommodates age and gender. This method, although level 2 of reliability, is accurate to approximately 3.9% either way of calculation (Australian Fitness Norms - Health Development Foundation 1996). Required body fat skin-fold percentage:
BODY SKIN FOLD	Recommended	Marginal	Not Recommended
Male	20% or less	Between 20 to 23.9%	Over 23.9%
Female	30% or less	Between 30 to 33.9%	Over 33.9%
GRIP TEST – Conducted by Medical Officer
Dominant Hand	Non Dominant Hand
Male	45 kgs	40 kgs
Female	35 kgs	30 kgs
FIT FOR DUTY TEST – Conducted by Operational Safety Training Unit
To carry out operational duties, you must complete our ‘fit for duty’ fitness test. As part of this test, you’ll wear a 10kg vest and need to complete the following exercises within 2 minutes and 30 seconds. Run 80 meters Run 25 meters carrying two 15kg weights Cross a slippery balance beam Do 20 step-ups Climb over a one-meter-tall fence Drop to the ground and stand up five times Collect a training firearm and pull the trigger 13 times with each hand
POLICE ACADEMY FITNESS STANDARDS
MALE
AGE	2.4km Run (m.s)	Obstacle Course (m.s)	Physical Capacity Assessment – obstacle course (m.s)	Physical Capacity Assessment – row LWT (75kg or less) (meters in 4 mins)	Physical Capacity Assessment – row LWT (over 75kg) (meters in 4 mins)
18 - 29	11.40	3.00	2.30	962	1000
30 - 39	12.50	3.00	2.30	946	957
40 - 49	14.10	3.00	2.30	927	938
50 - 59	15.00	3.00	2.30	891	901
FEMALE
AGE	2.4km Run (m.s)	Obstacle Course (m.s)	Physical Capacity Assessment – obstacle course (m.s)	Physical Capacity Assessment – row LWT (75kg or less) (meters in 4 mins)	Physical Capacity Assessment – row LWT (over 75kg) (meters in 4 mins)
18 - 29	14.30	3.15	2.30	798	824
30 - 39	16.10	3.15	2.30	769	776
40 - 49	17.00	3.15	2.30	749	763
50 - 59	17.40	3.15	2.30	730	756
For more information regarding health and fitness requirements please visit www.achievemore.com.au