WORK ENVIRONMENT ASSESSMENT () all relevant boxes Date of assessment: DD/MM/YYYY PAH Industry Controls: Coke Plant Aluminium Plant Wear gloves Yes No Roofing Industry Respirator use Yes No Road Surfacing Local exhaust ventilation Yes No Automotive Industry (diesel) Overalls / work clothing Yes No Other (specify): __________ Laundering by employer Yes No Wash basins & showers (with hot & Yes No cold water) Smoking or eating in workshop Yes No Personal hygiene: Clean Shaven Yes No Shower & change into clean Yes No clothes at end of shift BIOLOGICAL MONITORING RESULTS Include at least the previous two test results (if available) Date Test Performed Recommended Action and/or Comment 1. DD/MM/YYYY 2. DD/MM/YYYY 3. DD/MM/YYYY 4. DD/MM/YYYY 5. DD/MM/YYYY 6. DD/MM/YYYY 7. DD/MM/YYYY RECOMMENDATIONS (by Medical Practitioner) () all relevant boxes Suitable for work with PAH Counselling required Review workplace controls Repeat health assessment in ______ month(s) / ______ week(s) Removal from work with PAH On DD/MM/YYYY Medical examination by Medical Practitioner On DD/MM/YYYY Fit to resume PAH risk work From DD/MM/YYYY
WORK ENVIRONMENT ASSESSMENT () all relevant boxes Date of assessment: DD/MM/YYYY PAH Industry Coke Plant Aluminium Plant Roofing Industry Road Surfacing Automotive Industry (diesel) Other (specify): __________ Controls: Wear gloves Yes No Respirator use Yes No Local exhaust ventilation Yes No Overalls / work clothing Yes No Laundering by employer Yes No Wash basins & showers (with hot & cold water) Yes No Smoking or eating in workshop Yes No Personal hygiene: Clean Shaven Yes No Shower & change into clean clothes at end of shift Yes No BIOLOGICAL MONITORING RESULTS Include at least the previous two test results (if available) Date Test Performed Recommended Action and/or Comment 1. DD/MM/YYYY 2. DD/MM/YYYY 3. DD/MM/YYYY 4. DD/MM/YYYY 5. DD/MM/YYYY 6. DD/MM/YYYY 7. DD/MM/YYYY RECOMMENDATIONS (by Medical Practitioner) () all relevant boxes Suitable for work with PAH Counselling required Review workplace controls Repeat health assessment in ______ month(s) / ______ week(s) Removal from work with PAH On DD/MM/YYYY Medical examination by Medical Practitioner On DD/MM/YYYY Fit to resume PAH risk work From DD/MM/YYYY
hazardous-chemicals-requiring-health-monitoring.docx