PERSON

PERSON REPORTING

  • First names

  • Surname

  • Address
  • Date of birth

  • National Insurance number

  • Email address

  • Phone number

  • Mobile phone number

REPORT MEETINGS

  • Meetings record

  • meeting
  • Meeting type

  • Meeting date

REPORT WORK ACTIVITIES

  • Department

  • Post held

  • Approximate start date in post

  • Report on work activities

  • work activity
  • Work activity

CHECKS MADE

SKIN SURVEILLANCE FOLLOW UP

  • Reason for inquires

SKIN HAZARDS & RISKS

  • Follow up

  • Common skin hazards are:
    Agricultural type work - with artificial fertilisers, fuels, solvents, wet work, handling plants, wood dust etc;
    Carpentry type work - dusts, wood preservatives, dyes, fungicides, glues, solvents, varnishes, wood dust, etc
    Cleaning type work - detergents, cleaning products, solvents, wet work, etc
    Construction type work - cement, dusts, solvents, wet work, building materials, etc
    Metalworking - cutting oils & fluids, solvents, metal shavings, chromium metal, nickel metal, etc
    Painting & decorating type work - aggressive hand cleaners, solvents & thinners, chromium, nickel, etc
    Veterinarian type work - animal proteins, animal excreta and secreta, disinfectants, wet work, anaesthetics, antibiotics, antiseptics, formaldehyde, gluteraldehyde, latex, etc

  • Is this person exposed to skin risks at work (such as organic solvents, oils, detergents, cleaning materials, etc)

  • Are precautions taken to prevent expose.

SKIN SYMPTOMS SUFFERED

  • Follow up

  • Does the person suffer from skin problems

  • If they suffer from a skin problem, then record what problem they suffer from and which part of the body is affected.

  • Does the condition appear to be caused or aggravated by something used at work

  • Does the condition make work more difficult

  • Treatment for skin problem

  • Are they receiving treatment for their skin problem

  • Are you seeing a doctor for the current skin problem. Have they provided any advice and guidance.

  • Confounding factors

  • Do they have any activities outside of work that may cause skin problems

RESPIRATORY SURVEILLANCE FOLLOW UP

  • Reason for inquires

RESPIRATORY HAZARDS & RISKS

  • Follow up

  • Common respiratory hazards are:
    Animal and plant proteins; some wood dusts; isocyanates; and gluteraldehyde

  • Is this person exposed to respiratory risks (such as wood dust, silica dust, sensitising chemicals, etc)

  • Are controls in place to prevent or reduce expoure

RESPIRATORY SYMPTOMS SUFFERED

  • Follow up

  • Life style factors that may cause respiratory symptoms

  • Does the subject smoke

  • How many per day

  • General symptoms suffered that may indicate development of a chronic condition

  • Symptoms suffered include eye irritation, soreness or watering of eyes

  • Symptoms suffered include persistant coughs, bouts of coughing or phlegm

  • Symptoms suffered include being woken at night with coughing or chest tightness

  • Symptoms suffered include recurring blocked nose, running nose or nasal irritation

  • Specific symptoms that may indicate an existing chronic condition

  • Medical consultation for respiratory problems (eg chronic bronchitis)

  • Diagnosed as suffering from asthma

HAVS SURVEILLANCE FOLLOW UP

  • Reason for inquires

HAVS HAZARDS & RISKS

  • Follow up

  • Equipment that might cause HAVS are: chainsaws; concrete breakers & road breakers; cut off saws; hammer drills; hand held grinders; impact wrenches; jigsaws; needle scalers; pedestal grinders; polishers; power hammers & chisels; powered lawn mowers; powered sanders; scabblers; strimmers & brush cutters; etc

  • Details of past exposure to vibration

  • HISTORY
  • Approximate dates

  • Exposure to vibration

  • Details of current exposure to vibration

  • CURRENT
  • Approximate year of first exposure

  • Exposure source

  • Frequency of exposure to this source

HAVS SYMPTOMS SUFFERED

  • Follow up

  • Do they suffer from tingling of the fingers lasting more than 20 minutes after using vibrating equipment

  • Do they suffer from tingling of the fingers when not using vibrating equipment

  • Do they wake at night with pain, numbness or tingling in their hand(s) or wrist(s)

  • Do the fingers or hands go numb more than 20 minutes after using vibrating equipment

  • Have the fingers gone white on cold exposure

  • Do they have difficulty in warming fingers or hands when leaving the cold

  • Do there fingers or hands go white at any other time

  • Are they experiencing any other problems with the muscles or joints of the fingers, hands, wrists, arms or shoulders

  • Do they have difficulty picking up small objects (eg screws, button, etc)) or difficulty in gripping objects (eg container lids, pens, etc)

  • Do they have any neck, arm or hand injuries or have they had surgery to correct arm or hand injuries

  • Do they have any significant diseases of the joints, skin, nerves, heart or blood vessels that need to be taken into account

  • Are they taking any medication on a long term basis

  • Do they use any personal protective equipment to protect from the effects of vibration

SIGNATURES

Signatures

  • Person completing this report

  • Subject of this report

  • Others in attendance at the meeting

  • attendees
  • Signature

OUTCOME

Further action required

  • Respiratory surveillance follow up outcome

  • Skin surveillance follow up outcome

  • HAVS surveillance follow up outcome

Recomendations

  • Add recommendations and further actions needed

  • RECOMMENDATION
  • Title - short one liner

  • Department to action

  • Recomendation

  • Target date for completion

Signature

  • Person completing this report

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