WORK ENVIRONMENT ASSESSMENT () all relevant boxes Date of assessment: DD/MM/YYYY Crystalline Silica Industry Excavation/Earth Moving Drilling Plant Clay/Stone Processing Paving/Surfacing Mining Construction Abrasive Blasting Foundry Casting Other (specify): ___________ Controls: Respirator use Yes No Local exhaust ventilation (if indoors) Yes No Overalls / work clothing Yes No Laundering by employer Yes No Wash basins & showers (with hot & cold water) Yes No Wet handling methods used where possible 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 Tests performed Recommended Action and/or Comment 1. DD/MM/YYYY Last Chest X-Ray DD/MM/YYYY Results: Normal / Abnormal ________________________________________ 2. DD/MM/YYYY Spirometry Results: FEV1 ____________; FVC __________ FEV1/FVC __________________ 3. DD/MM/YYYY 4. DD/MM/YYYY 5. DD/MM/YYYY 6. DD/MM/YYYY 7. DD/MM/YYYY 8. DD/MM/YYYY RECOMMENDATIONS (by Medical Practitioner) () all relevant boxes Suitable for work with crystalline silica Counselling required Review workplace controls
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:
GENERAL HEALTH ASSESSMENT (if applicable) Symptoms of: Comments Further testing? Skin disorders Yes No Headaches, dizziness Yes No Respiratory disorders Yes No Irritation of eyes, nose or throat Yes No Cough Yes No CNS Yes No Peripheral nervous system symptoms Yes No Others: Pregnant Breastfeeding Smoker Yes No Yes No Yes No Yes No Height _____cm Weight _____kg Bp ____/____ mmHg OTHER MEDICAL HISTORY, FAMILY MEDICAL HISTORY, CURRENT MEDICATION, COMMENTS, TESTS OR RECOMMENDATIONS (use separate sheet if necessary)
Baseline 1 (B1) Test when exposure-free for 30 days Baseline 2 (B2) Re-test 3-14 days later, exposure-free Baseline 3 (B3) Re-test only if (B1)-(B2) exceeds 20% Average of Baseline results Compare test results to Baseline results Test date RBC Cholinesterase (kU/L) Plasma Cholinesterase (kU/L) Timing Comment % fall in cholinesterase Pre-shift Post-shift Pre-shift Post-shift Pre-shift Post-shift Note: Baseline – Ideally two pre-exposure tests should be performed at least three days apart, no sooner than 30 days after prior exposure. Reliability is indicated by the two tests being within 10% of each other. Periodic testing should occur during the period of organophosphate pesticide use (latter half of work day). ≥ 20% fall in cholinesterase – Re-test ≥ 40% fall in cholinesterase – Remove from exposure until test results return to baseline level. 6B – Urinary metabolite test (dialkyl phosphate (DAP) metabolites) Test date Urinary DAP metabolites (µmol/mol creatinine) Timing Comment Pre-shift Post-shift Next day Pre-shift Post-shift Next day Pre-shift Post-shift Next day Note: <100 µmol/mol creatinine – considered low work exposure. 100-1000 µmol/mol creatinine – indicates work exposure – review workplace controls to reduce exposure levels. >1000 µmol/mol creatinine – indicates high work exposure; may be associated with a fall in blood cholinesterase levels. RECOMMENDATIONS (by Medical Practitioner) () all relevant boxes Suitable for work with organophosphate pesticides Counselling required
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