/ UNIVERSITY MEDICAL SERVICES
OCCUPATIONAL HEALTH

RESPIRATORY/SKIN SURVEILLANCE

This questionnaire should be completed by people whose work activity will potentially expose them to substances that may cause occupational asthma or skin disease. If the individual is found to be fit for the activity, surveillance should be repeated again at six weeks after the work activity has commenced, and annually thereafter (unless the university occupational health adviser determines otherwise).

PLEASE COMPLETE AND BRING WITH YOU TO YOUR APPOINTMENT

Personal information:

Surname: / Dept/School:
Forename: / Manager/Supervisor:
Date of Birth: / Role / Job Title:
Height: Weight: / Research Code:

Previous hazard exposure:

During past employment have you ever worked with any respiratory or skin sensitisers?
If yes please provide details: Yes
No
Did you suffer any ill effects from working with these substances?
If yes please provide details: Yes No Not
applicable

Present exposure History:

Give details of respiratory/skin sensitisers you will be working with?
Do you have contact with similar chemicals at home or in other employment?
If yes please provide details: Yes No
How many hours on average per week will you spend working with these substances?
Have you been supplied with gloves/masks/PPE for use when working with these substances? Yes No
Do you always wear the gloves/masks/PPE provided? Yes No
Have you had any problems with your health since starting your current role?
Yes No

Current/History Information: If Yes, please give details

Do you have Asthma or Dermatitis? / Yes / No / If Yes to Asthma what inhalers do you take?
Do you have any allergies (including hayfever)? / Yes / No
History or family history of chronic lung disease/cancer? / Yes / No
Have you ever consulted your doctor about chest problems? / Yes / No
Do you have recurrent chest infections? / Yes / No
Do you smoke? / Yes / No / Amount
Have you ever smoked? / Yes / No / Amount How long ago did you stop?
Are you currently taking any medications? / Yes / No

Symptoms:

Have you ever had or are you currently suffering from any of the following? (do not include isolated colds, sore throats or flu) Details

Wheezing, shortness of breath or chest tightness during your normal working day? / Yes / No
Stuffiness of your nose, nasal catarrh, itchy nose or bouts of sneezing? / Yes / No
Bouts of coughing? / Yes / No
Skin Rashes or irritations? / Yes / No
Itchy, sore, red or excessive watering of the eyes? / Yes / No
Do you usually bring up phlegm first thing in the morning? / Yes / No
When did you first notice these symptoms?
Are the symptoms worse in particular places (e.g. dusty environment)? / Yes / No
If you have symptoms, do any of them improve when away from work? / Yes / No
CONSENT AND DECLARATION
I confirm that the above responses by me are correct. The purpose of this assessment has been fully explained to me and I have consented to health surveillance regarding my fitness for work in relation to potential hazardous substances following COSHH guidelines.
I understand that I have a duty to report any possible symptoms of allergic reactions to substances encountered in my work to my Manager as soon as possible. I understand that Occupational Health will inform management on my fitness to work with respiratory and/or skin sensitisers.
Signed: / Date:

1

JG/vf/May 2014

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