I………………………………………wish to register that I have worked in an area that contains asbestos and as a result of this I believe that I have or could have inhaled asbestos particles.
I understand that providing I maintain my membership in UCATT, the union will keep a record of the following information, and that all such information will be made available to either myself or a person or persons acting on my behalf. I also confirm that I shall retain a copy for my own records.
I confirm that asbestos was/still is present at the following address and that I did/may have come into contact with it (delete as appropriate).
Employer’s name
……………………………………………………………………………………………………………………………………………………………………………………
Employer’s address………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Department/location of possible contact ……………………………………………………………………………………………………………………………………………………………………………………
Member’s full name…………………………………………………………………………………………..
Home address ……………………………………………………………………………………………………………………………………………………………………………………
UCATT National Number ……………………………
Member’s National Insurance Number …………………………….
UCATT Branch …………………………………………………………………………………………..
Date …………………… Signature……………………………………......
OTHER INFORMATION REQUIRED (fill in as much as possible)
1)A full list of your employment history indicating where you were exposed to asbestos dust. …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
2) Names and addresses of any colleagues who can verify contact with asbestos. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
3) The nature of the work you were doing at the time you were exposed to the dust. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
4) The dates when you were exposed to the dust or if you were exposed to the dust for a period of time, from when to when.
…………………………………………………………………………………………..…………………………………………………………………………………………..
5) The insurance details of the relevant employer(s), if known.
…………………………………………………………………………………………………………………………………………………………………………………...
6) If possible, a signed statement from the employer(s) confirming you have been exposed to asbestos dust (use separate sheet).
7) Do you know whether the Health and Safety Executive has successfully prosecuted any employer(s) you have named in question 1? …………………………………………………………………………………………
…………………………………………………………………………………………
8) Are you or have you ever been a smoker? If yes, please say what you smoke, how much and for how long. ……………………………………………………………………………………………………………………………………………………………………………………
Further information
One of the reasons for setting up the Asbestos Register is to allow members to register their details in case they are unfortunate enough to develop an asbestos-related condition in later life. As an asbestos related condition usually has a long incubation period (anything between 5–50 or more years), it is advisable to obtain details about exposure while they are still available.
In order to succeed with a civil law claim it must be possible to prove that another party (usually an employer, and/or occupier) acted in breach of his duty of care (i.e. acted negligently), as a result of which the employee suffered foreseeable injury (an asbestos-related disease). Apart from proving negligence, it must also be possible to establish that the disease is work-related.
Please be advised that anyone who is unfortunately diagnosed as suffering from an asbestos-related condition must start their compensation claim within three years from the date when the person suffering the condition became aware of the diagnosis.
It is also possible to apply for benefits relating to prescribed industrial disease conditions.The Union has its own industrial disease forms which are available to members either from the branches or Regional Offices.
For many years now UCATT has supported members who have submitted civil law claims for an asbestos-related disease. The solicitors we instruct are specialists in work-related disease claims and work-related accident claims.
We trust the above will be of assistance to you.
Steve Murphy
General Secretary
Return this form to:
Asbestos Register, UCATT, UCATT House, 177 Abbeville Road, London SW4 9RL