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

Continue on a separate sheet if you have worked in more than 4 companies.

Please answer the following: / (Please circle) / Comments and details
Have you ever used hand-held vibrating tools, machinery or hand-fed processes as part of your job? / Yes / No / If yes, in what year did you start using them?
Do you have any tingling or numbness in your fingers or hands that lasts longer than 20 minutes after using vibrating equipment? / Yes / No / Details
Do you have any tingling or numbness in your fingers or hands at any other times? / Yes / No / Details
Do you ever wake up at night with pain, tingling or numbness in your fingers, hands or wrists? / Yes / No / Details
Do your fingers ever go white when exposed to the cold?
‘White’ means a substantial discoloration of the finger(s) with a demarcation line and then normal colour / Yes / No / Details
If yes, do you have pain or discomfort with rewarming hands/fingers YES/NO
Do you have any other problems with the muscles or joints in your neck, shoulders or upper limbs? / Yes / No / Details
Have you ever had any health issues involving the following:
Circulation e.g. heart, Raynaud’s
Joints e.g. arthritis
Nerves e.g. carpal tunnel / Yes / No
Yes / No
Yes / No / Details
Are you on long term medication Do you suffer from any allergies?
If yes, please give details / Yes / No / Details
Do you have any difficulties picking up small items e.g. screws/ buttons or opening tight jars etc. / Yes / No / Details
Do you have or had any hobbies involving vibration e.g.
Motorbikes, Go-carting, using gardening tools e.g. strimmers or DIY drills etc. on more than just an occasional basis e.g. 1 -2 hours cumulative per week / Yes / No
Do you smoke? / Yes / No / If yes, how many?
If you used to smoke, when did you give up?

CONSENT TO TAKE PART IN HEALTH SURVEILLANCE PROGRAMME

I understand that a risk assessment of my workplace has indicated that a health surveillance programme is required in this employment. I understand that I will be given a copy of the results which will be explained to me. My employer will be given advice about my fitness for work and any adjustments or precautions necessary which will form my health record held by my employer.

Print Name .………………………….……….………………………………………………..

Signature…………………………………………………………….Date………………………

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