Exposure source Exposure If Yes, please provide details below history Name of place or brand, address/location and relevant dates Yes General gardening activities No Unknown Yes Washed hands routinely after No gardening activities Unknown Yes Use potting mix or landscaping No materials Unknown Yes Prior knowledge of risks from No potting mix or landscaping Unknown materials Yes Wore gloves No Unknown Yes Wore mask No Unknown Yes Watered hanging baskets No Unknown Yes Visited a plant No nursery/gardening Unknown centre/landscaping centre PLACE ACQUIRED: Within the state Other Australian state/territory – specify Other country – specify Unknown ………………………………………. ENVIRONMENTAL ASSESSMENT: Was an environmental assessment undertaken? Yes No Unknown If Yes, Date commenced: ......../......../........ Details: ADDITIONAL COMMENTS:
Exposure source Exposure history If Yes, please provide details below Name of place or brand, address/location and relevant dates General gardening activities Yes No Unknown Washed hands routinely after gardening activities Yes No Unknown Use potting mix or landscaping materials Yes No Unknown Prior knowledge of risks from potting mix or landscaping materials Yes No Unknown Wore gloves Yes No Unknown Wore mask Yes No Unknown Watered hanging baskets Yes No Unknown Visited a plant nursery/gardening centre/landscaping centre Yes No Unknown PLACE ACQUIRED: Within the state Other Australian state/territory – specify Other country – specify ………………………………………. Unknown ENVIRONMENTAL ASSESSMENT: Was an environmental assessment undertaken? Yes No Unknown If Yes, Date commenced: ......../......../........ Details: ADDITIONAL COMMENTS:
wLegionellosis-investigation-form.docx