HEALTH SURVEILLANCE CONSENT FORM

HEALTH SURVEILANCE CONSENT FORM

First name

Last name

NI Number

Address

Phone

DOB

Month

Day

Year

GP Name

GP Address

Company name

Position

OCCUPATIONAL HISTORY

Company

Address

Start Date

Finish Date

Have you previously attended for health surveillance?

If yes, please state where?

IMPORTANT

Please tick that you understand

Some Health and Safety Regulations (for example those for noise, vibration, asbestos, lead, solvents etc.) require employers to provide health surveillance for employees. In their turn employees have a responsibility to comply, attend for and participate in the required health surveillance.

Failure to give consent will result in the health surveillance NOT being undertaken and your manager will be accordingly advised.

A certificate of attendance, including the outcome of the health surveillance will be provided to your employer, a copy can be given to you upon request.

Results may be copied to your own General Practitioner.

You may be referred to an Occupational Health Doctor for further tests if necessary.

Please see further information about health surveillance on the back of this form.

DECLARATION

I certify that the information I have given in questionnaires is correct and I have not withheld any relevant information

I consent to undergo health assessment and allow the information outlined overleaf to be reported to my employer

I understand the purpose of the assessment is to provide my employer with information regarding my fitness to work and any advice will be expressed in terms of fitness to carry out my duties now and in the future

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Date

Month

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Signature

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NOTES

Health surveillance is about systematically watching out for early signs of work-related ill-health in employees exposed to certain health risks. It means putting in place certain procedures to achieve

this. These procedures include:

Simple methods, such as looking for skin damage on hands from using certain chemicals
Technical checks on employees, such as hearing tests
More involved medical examinations e.g. where employees are exposed to vibration

Some health and safety regulations require employers to provide health surveillance for their employees. Health surveillance provides information which helps to protect employees from illness caused by being exposed to health risks at work. It enables risks to be managed effectively by acting

as a check on:

How control measures are working
Providing a valuable opportunity for feedback from employees and a chance to reinforce health and safety messages

The following table shows examples of tests performed as part of the health surveillance screening process and what information is reported accordingly:

Lung Function Test

To ensure any hazardous materials you may be exposed to do not affects your lungs: in line with

COSHH regulations

Lung Function Test

The outcome will be reported to your employer as satisfactory, or advice regarding any work restrictions or further actions that may be required

Hearing Test

To ensure that your hearing

is not affected by any loud noises that you are exposed to in your area of work: in line with Noise at Work Regulations

Hearing Test

The HSE Hearing category will be reported to your employer with advice regarding any work restrictions or further action required

Skin Checks

To ensure that any hazardous

material you come into contact with is not damaging your skin: in line with COSHH

Skin Checks

The outcome of skin checks will be reported to your employer as satisfactory or with advice regarding any work restrictions or further action that may be required

Hand Arm Vibration (HAVS)

To identify symptoms related to vibration from work processes or tools in line with the Control of

Vibration at Work Regulations

Hand Arm Vibration (HAVS)

The outcome of HAVS checks will be reported to your employer as satisfactory or advice regarding any work restrictions or further action that may be required

Specific results of height, weight, blood pressure and information from your health questionnaire will not be given to your employer.

Following any health assessment your employer will be given advice regarding work restrictions or modifications that may be necessary, and or your fitness for work.

You may be referred to an Occupational Health Doctor for further tests if necessary, or a copy of your results may be sent to your own General Practitioner.

DATA PROTECTION

Information about your health, medical history and any treatment you have received is classified as sensitive personal data under the Data Protection Act 1998. Eaton Occupational Health require your written and informed consent to obtain and process any health related sensitive personal data about you for the purposes of delivery of health care to you. Eaton Occupational Health will store data in a secure environment and it will only be accessed and processed by those staff that have a requirement to do so and made available to those who you have indicated your consent to receive specific records.

Eaton Occupational Health United Kingdom

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