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RESPIRATORY AND SKIN HEALTH SURVEILLANCE FORM

PART 1 – To be completed by the Employee

DOB
Month
Day
Year

Respiratory and Skin Protection

Do you wear respiratory protection at work?
If ‘YES’, what do you wear?
Do you use protective gloves?
Do you use pre-work skin care lotions?
Do you use after-work skin care lotions?

General Health

Please tick if you have had any of the following in the last 6 weeks
Please tick if you have had any of the following in the last 12 weeks

About your respiratory health

Do you have, or have you had (not including colds/sore throats/flu)

Recurring soreness/watering eyes
Frequent blocked or runny nose
Coughing bouts / persistent cough
Chest tightness
Wheezing
Breathlessness
Any other chest problem
Have you ever consulted a doctor about respiratory symptoms?
If ‘YES’, were you told you had asthma or any other chest complaint?
Have you ever injured your chest in an accident or had a chest operation?
Do you smoke?

About your skin

Do you have any problems with your skin?

If ‘YES’, please continue with the questionnaire.

Have you seen a Doctor about your skin problem?
Do you suffer from skin allergies?
Have you had treatment for a skin problem since starting your current job?

DECLARATION

I understand that a programme of health surveillance is necessary in this employment and will form part of my Occupational Health record. I certify that all the answers given above are true to the best of my knowledge and belief. I understand that no medical details will be divulged without my

permission to any person outside Occupational Health, but an opinion about my fitness for night work will be issued to management.

Employee Signature

Date
Month
Day
Year

Part 2 – to be completed by occupational health

If offsite please note the spirometer’s:

Lung Function

Actual

Predicted

%

Recommendations

Information Provided
Outcome

Assessor

Date
Month
Day
Year
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