THIS INFORMATION IS CONFIDENTIAL TO WORKING WELL Working Well, The Orchard Centre, Gloucestershire Royal Hospital, Gloucester, GL1 3NN T: 01452 894480, E: Issue 2: Oct 2015 TIER 1 HAND/ARM VIBRATION (HAV’s) INITIAL ASSESSMENT WWF-022 PERSONAL DETAILS OPAS No: Employee Name: Date of Birth: Age: Address: Mobile No: EMPLOYMENT DETAILS CURRENT – Employer: Job Title: Location/Department if applicable: Line Manager: When did you start this role? Full time/Part-time Hours of work: EMPLOYMENT DETAILS - PREVIOUS 1. Name of firm: How long did you work for this company? Were you this role? Was PPE required Yes/No exposed to HAV’s in Yes/ No If yes, what was it If yes, give details. If yes, did you wear it Yes/No 2. Name of firm: How long did you work for this company? Were you this role? Was PPE required Yes/No exposed to HAV’s in Yes/ No If yes, what was it If yes, give details. If yes, did you wear it Yes/No 3. Name of firm: How long did you work for this company? Were you this role? Was PPE required Yes/No exposed to HAV’s in Yes/ No If yes, what was it If yes, give details. If yes, did you wear it Yes/No How long did you work for this company? 4. Name of firm: Were you this role? Was PPE required Yes/No exposed to HAV’s in Yes/ No If yes, what was it If yes, give details. If yes, did you wear it Yes/No
THIS INFORMATION IS CONFIDENTIAL TO WORKING WELL Working Well, The Orchard Centre, Gloucestershire Royal Hospital, Gloucester, GL1 3NN T: 01452 894480, E: TIER 1 HAND/ARM VIBRATION (HAV’s) INITIAL ASSESSMENT Issue 2: Oct 2015 WWF-022 PERSONAL DETAILS OPAS No: Employee Name: Date of Birth: Age: Address: Mobile No: EMPLOYMENT DETAILS – CURRENT Employer: Job Title: Location/Department if applicable: Line Manager: When did you start this role? Full time/Part-time Hours of work: EMPLOYMENT DETAILS - PREVIOUS 1. Name of firm: How long did you work for this company? Were you exposed to HAV’s in this role? Yes/ No If yes, give details. Was PPE required Yes/No If yes, what was it If yes, did you wear it Yes/No 2. Name of firm: How long did you work for this company? Were you exposed to HAV’s in this role? Yes/ No If yes, give details. Was PPE required Yes/No If yes, what was it If yes, did you wear it Yes/No 3. Name of firm: How long did you work for this company? Were you exposed to HAV’s in this role? Yes/ No If yes, give details. Was PPE required Yes/No If yes, what was it If yes, did you wear it Yes/No 4. Name of firm: How long did you work for this company? Were you exposed to HAV’s in this role? Yes/ No If yes, give details. Was PPE required Yes/No If yes, what was it If yes, did you wear it Yes/No
HAVs-Tier-1-Form.docx