Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

General Patient Information

  • Surname

  • Full Names

  • ID number/ Passport number (non South African Citizen only)

  • Employee Number

  • Address of Employee
  • Contact telephone number

Employer information

  • Tharisa Minerals
    Portion 84 of K/Kraal
    Farm 342JQ

    Postnet Suite 473
    Private Bag X51
    Bryanston
    2021

  • Are you employed by Tharisa Minerals or Sub Contracting company?

  • Contractor information

  • Specify employer details

Occupation

  • Jop Title

  • Section

Physical Enviroment

  • Lighting

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Noise

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Radiation ( non ionizing)

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Tempreture Highest

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Humidity

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Tempreture lowest

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Radiation ( non ionizing)

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Vibration

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Infection

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Slippery

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Confined spaces

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

  • Heights

  • Quantative Measurement

  • Qualitative Assessment

  • Hours of exposure in a 40 hour week

  • Hours of exposure in a 8 hour day

Chemicals

  • Exposure to Chemicals

  • Which Chemicals

  • Chemical
  • Name

Special Requirements

  • Item

Initial Medical Examination

1. Body Mass Index

  • Weight in kg

  • Height in cm

  • BMI

2. Skin

  • Skin

  • Discription of abnormality

3.Cardio Vascular System

  • Pulse per minute

  • Blood Pressure

  • Systolic

  • Diastolic

  • Heart Sounds

  • Murmurs

4.Resparatory System

  • PEF in litres per minute

  • Nasal Septum

  • Discription of abnormality

  • Breath sounds

  • Discription of abnormality

  • Chest X-rays

  • Discription of abnormality

  • Lung Function report

  • Discription of abnormality

Abdominal Examination

  • Urinalysis

  • Glucose

  • Protein

  • Blood

  • Nitrate

6. Vision

  • Test Conducted with or without Spectacles

  • Left Eye Acuity

  • Right Eye Acuity

  • Colour Vision

  • Depth Perception (stereopsis)

  • Discription of abnormality

  • General inspection

  • Discription of abnormality

7. Ears

  • Left Ear

  • Discription of abnormality

  • Right Ear

  • Discription of abnormality

  • Audiogram Report Left Ear

  • Discription of abnormality

  • Audiogram Report Right Ear

  • Discription of abnormality

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