Audit

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

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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

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.