HSE HAVS Assessment Template

• Date

  Date

• Employee Name

• Occupation

• Address
  Address

• Date of Birth

  Date

• National Insurance No.

HSE HAVS Assessment

• MEDICAL IN CONFIDENCE

• Have you ever used hand-held vibrating tools, machines or hand-fed processes in your job?

  Yes

  No

• Indicate the year of first exposure

• Do you have any tingling of the fingers lasting more than 20 minutes after using vibrating equipment?

  Yes

  No

• Do you have tingling of the fingers at any other time?

  Yes

  No

• Do you wake at night with pain, tingling, or numbness in your hand or wrist?

  Yes

  No

• Do one or more of your fingers go numb more than 20 minutes after using vibrating equipment?

  Yes

  No

• Have your fingers gone white on cold exposure?

  Yes

  No

• Do you have difficulty rewarming them when leaving the cold?

  Yes

  No

• Whiteness means a clear discoloration of the fingers with a sharp edge, usually followed by a red flush.

  

• Do your fingers go white at any other time?

  Yes

  No

• Are you experiencing any other problems with the muscles or joints of the hands or arms?

  Yes

  No

• Do you have difficulty picking up very small objects, e.g. screws or buttons or opening tight jars?

  Yes

  No

• Have you ever had a neck, arm or hand injury or operation?

  Yes

  No

• Give details

• Have you ever had any serious diseases of joints, skin, nerves, heart or blood vessels?

  Yes

  No

• Give details

• Are you on any long-term medication?

  Yes

  No

• Give details

Occupational History

• Job Title

JOB

• Job Title

• Start Date

  Date

• End Date

  Date

Completion

• I certify that all the answers given above are true to the best of my knowledge and belief.

• Full Name and Signature of Employee

  Sign