Title Page
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Date
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Employee Name
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Occupation
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Address
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Date of Birth
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National Insurance No.
HSE HAVS Assessment
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MEDICAL IN CONFIDENCE
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Have you ever used hand-held vibrating tools, machines or hand-fed processes in your job?
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Indicate the year of first exposure
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Do you have any tingling of the fingers lasting more than 20 minutes after using vibrating equipment?
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Do you have tingling of the fingers at any other time?
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Do you wake at night with pain, tingling, or numbness in your hand or wrist?
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Do one or more of your fingers go numb more than 20 minutes after using vibrating equipment?
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Have your fingers gone white on cold exposure?
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Do you have difficulty rewarming them when leaving the cold?
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Whiteness means a clear discoloration of the fingers with a sharp edge, usually followed by a red flush.
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Do your fingers go white at any other time?
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Are you experiencing any other problems with the muscles or joints of the hands or arms?
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Do you have difficulty picking up very small objects, e.g. screws or buttons or opening tight jars?
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Have you ever had a neck, arm or hand injury or operation?
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Give details
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Have you ever had any serious diseases of joints, skin, nerves, heart or blood vessels?
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Give details
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Are you on any long-term medication?
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Give details
Occupational History
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Job Title
JOB
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Job Title
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Start Date
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End Date
Completion
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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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Full Name and Signature of Employee
