Worksafe Health Surveillance - Notification: Other
WorkSafe Health Surveillance - Notification: Other
Occupational Safety and Health Act 1984; Regulation 5.24
Confidential
HAZARDOUS SUBSTANCE:
Please complete all sections neatly. A copy of spirometry must be attached where relevantReturn to : Occupational Physician, WorkSafe, Locked Bag 14, Cloisters Square PERTH WA 6850
Tel: 6251 2200 Fax: 6251 2827 Email:
1.EMPLOYER(Principal)
Company/Organisation name:Site address:
Site Tel: / Employer Email: / Contact Name:
Mobile
2. LABOUR HIRE (if worker is employed through Agency)
Company/Organisation name:Address:
Tel: / Email: / Contact Name:
3.EMPLOYEE / WORKER() all relevant boxes
Last name: / Given names:Date of birth / Male / Female
Address:
Current Job: / Tel (h): / Mob:
4.EMPLOYMENT IN WORK WITH HAZARDOUS SUBSTANCE () all relevant boxes
New to hazardous substance workNot directly working with hazardous substanceCurrent employee continuing in hazardous substance work
Worked with hazardous substances since / (mm/yyyy)
With current employer since / (mm/yyyy)
Details of prior work with hazardous substance Date last worked:
Employer details:from / (mm/yyyy) to / (mm/yyyy)
Employer details:from / (mm/yyyy) to / (mm/yyyy)
Work industry:
Work Activity/Task (describe):
5.WORK ENVIRONMENT ASSESSMENT() all relevant boxes
Smoker Ex- Smoker Non-SmokerClean shaven Yes No
Shower & change into clean clothes at end of shift Yes No
Trained in hazardous substances processes and procedures Yes No
Wear gloves Yes No / Laundering by employee Yes No
Respirator use Yes No / Wash basins and showers Yes No
Local exhaust ventilation Yes No / Smoking or eating in workshop Yes No
Overalls/work clothing Yes No / Dry sweeping Yes No
Comments:
6.Where relevant SPIROMETRY (NHANES III preferred for spirometric predicted values)
1. Enter best test values for Baseline and Current test to enable comparisons.
2. Attach printouts with 3 valid tests (which meet ATS “acceptable blow” criteria) with flow-volume graphs.
3. If bronchodilator used, please attach printouts clearly marked pre- and post-bronchodilator.Enter Best Readings
/Date
/FEV1
/FVC
/FEV1 / FVC (%)
/Comment
Baseline values
/ / / / /Normal Acceptable
% predicted
/ / / / /Obstructive Restrictive
Current Test
/ / / / /Mixed Obstructive / Restrictive
% predicted
/ / / / /7.Where relevant BIOLOGICAL MONITORING Include at least the previous two test results (if available)
Type of test and units / Arsenic / Cadmium / Thallium/ Mercury / Benzene / Other
Date / Results / Recommended Action and/or comment
1. / / / / /
2. / / / / /
3. / / / / /
8.RISK ASSESSMENT (Appointed Medical Practitioner to complete) Indicate ()
New to hazardous substance workNew employee but with previous exposure of hazardous substances
Current employee continuing in hazardous substances work
Satisfactory personal hygiene Yes No
Satisfactory personal workplace controls Yes No
Clinical picture indicative of adverse health effects from hazardous substance exposure
Yes No Maybe
Comment:
9.RECOMMENDATIONS (by Appointed Medical Practitioner) () all relevant boxes
Suitable for work with hazardous substancesReview/repeat lung function test in / (months/weeks)
Review/repeat test in / (months/weeks)
Not suitable to work with hazardous substances
Remove from exposure to hazardous substances
Counselled employee
Informed employer to review and implement controls in workplace
Medical examination within 7 days on / /
Referral to medical specialist: Appointment date:
Occupational PhysicianRespiratory PhysicianPhysician (specify)
Suitable to resume hazardous substance work
Next review date: / /
Comments
Appointed Medical Practitioner (responsible for supervising health surveillance)
Name: / Signature: / Date: / /Tel: / Email: / Contact Person:
Medical Practice Address
Email:
For information or assistance, contact:
Occupational Physician or Occupational Health Nurse, WorkSafe : 6251 2200.
A20743267
Hazardous Substances Health Surveillance – WorkSafe WA - Notification form Revised 14/11/2017 Page 1 of 3