Name of referred individual……………………………………………………………………………………….……………….. Date of Birth…………….………..…Payroll No No for Individual Home…………………………… ………………….Contact Address of Individual……………………………………………………………………………………………………………….. Job / role of Individual……………………………………Campus/Location of Individual….…………………………………. 2. Health Surveillance Requirements Referring Manager / Responsible Person For completion by Number of Aspects of statutory individuals Tick surveillance / requiring this Reason this would be required box assessment aspect of required surveillance Audiology Exposure to 80dB(A) TWA or significant impact noise Exposure to COSHH Respiratory sensitizers or RSC COSHH Respiratory above the WEL COSHH Dermatology Exposure to COSHH Skin sensitizers HAVS Exposed to HTV exceeding 2.5m2 A tight fitting (none air fed) mask is a mandatory RPE Fit testing requirement in role Number of Aspects of individuals Tick requiring this surveillance or Reason this would be required box aspect of fitness for task surveillance assessment required Manual handling Significant MH activities or repetitive tasks Employees work 3 or more hours between 11pm and Night Time Workers 6am on a regular basis Site vehicle driving Drives university vehicle which does not go on a public (includes eye highway Confined space Required to access confined spaces assessment Working at heights Required to work at heights Lone worker Required to work alone Visual assessment Safety critical activity relative to vision
Name of referred individual……………………………………………………………………………………….……………….. Date of Birth…………….………..…Payroll No ………………….Contact No for Individual Home…………………………… Address of Individual……………………………………………………………………………………………………………….. Job / role of Individual……………………………………Campus/Location of Individual….…………………………………. 2. Health Surveillance Requirements For completion by Referring Manager / Responsible Person Tick box Number of individuals requiring this aspect of surveillance Aspects of statutory surveillance / assessment required Reason this would be required Audiology Exposure to 80dB(A) TWA or significant impact noise COSHH Respiratory Exposure to COSHH Respiratory sensitizers or RSC above the WEL COSHH Dermatology Exposure to COSHH Skin sensitizers HAVS Exposed to HTV exceeding 2.5m2 RPE Fit testing A tight fitting (none air fed) mask is a mandatory requirement in role Tick box Number of individuals requiring this aspect of surveillance Aspects of surveillance or fitness for task assessment required Reason this would be required Manual handling Significant MH activities or repetitive tasks Night Time Workers Employees work 3 or more hours between 11pm and 6am on a regular basis Site vehicle driving (includes eye Drives university vehicle which does not go on a public highway Confined space assessment Required to access confined spaces Working at heights Required to work at heights Lone worker Required to work alone Visual assessment Safety critical activity relative to vision
hsfacefithsrohv4-1.docx