Title Page
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Conducted on
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Full Name
Please read before completing this form
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SCREENING QUESTIONNAIRE FOR WORKERS USING HAND-HELD VIBRATING TOOLS, HAND-GUIDED VIBRATING MACHINES AND HANDFED VIBRATING MACHINES
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Have you been using hand-held vibrating tolls, machines or hand-fed processes in your job
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If you have answered NO or its 2+ years since last exposure please there is no need to answer further questions, please go to next section, sign & return.
If YES (ONLY ANSWER IF ANSWERED YES ABOVE) IF NO SIGN & RETURN
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Do you experience numbness / tingling of the fingers, lasting for over 20minutes after using vibrating equipment
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Do you have numbness / tingling if the fingers at any other time
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Do you wake up with pain, tingling or numbness in your hand or wrist
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Have any of your fingers gone white *on cold exposure (Whiteness is a clear discoloration of the fingers with a sharp edge, usually followed by a hot flush)
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Have you noticed any change in your response to your tolerance of working outdoors in the cold
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Are you experiencing any other problems in your hands or arms
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Do you have difficulty picking up very small objects, such as screws or buttons or opening tight jars.
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Has anything changed about your health since the last assessment
Declaration
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I certify that all the answers given above are true to the best of my knowledge and belief.
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Signed
