Repeat health assessment (including any tests) in ______ month(s) / ______ week(s) Specify tests to be repeated: ____________________________________________ Removal from work with crystalline On DD/MM/YYYY silica Medical examination by Medical Practitioner On DD/MM/YYYY Fit to resume work From DD/MM/YYYY Referred to Medical Specialist (respiratory/dermatology/other): On DD/MM/YYYY name: Specialist’s Additional comments or recommendations arising from health monitoring: Medical Practitioner (responsible for supervising health monitoring) Name: Signature Date: DD/MM/YYYY Tel: Fax: Registration Number: Medical Practice: Address: Suburb: Postcode:
Repeat health assessment (including any tests) in ______ month(s) / ______ week(s) Specify tests to be repeated: ____________________________________________ Removal from work with crystalline silica On DD/MM/YYYY Medical examination by Medical Practitioner On DD/MM/YYYY Fit to resume work From DD/MM/YYYY Referred to Medical Specialist (respiratory/dermatology/other): Specialist’s name: On DD/MM/YYYY Additional comments or recommendations arising from health monitoring: Medical Practitioner (responsible for supervising health monitoring) Name: Signature Date: DD/MM/YYYY Tel: Fax: Registration Number: Medical Practice: Address: Suburb: Postcode:
hazardous-chemicals-requiring-health-monitoring.docx