Impact on Your Ability to Undertake This Position; And/Or
HEALTH AND HAZARD ASSESSMENT QUESTIONNAIRE (HHAQ)
Section A : SUPERVISOR COMPLETES
employment / position details/LOcation
Employeename* / Department Name*
Building Number / Level Room
Position title* / Position no.
Duration of employment / From / To
Brief description of job responsibilities and role*
SUPERVISOR – Please clickthe following staff activity hazards if relevant to the job;
Wearing of hearing protection OR Working with lung irritants - See Section B Part 1
Working with scheduled hazardous substances / Prohibited or Restricted Carcinogens - See Section B Part 2
Section B Part 3
Working in childcare Working in healthcare
Working with animals Working in or visiting an abattoir
Working in laboratories with human tissue, blood, body fluids, tissues, primary cell lines
Working with infectious organisms Working in laboratories with bowel or faecal matter
Working with sewage, potentially contaminated water ways and rubbish collection
Working with Class 3B or Class 4 lasers – see Section B Part 4
SUPERVISOR-If you have NOT clicked any of the above staff activity hazards, please complete Section B Part 5 and forward to employee to complete Section C Part 1 and Section D.
If you have clickedYES to any of the above please complete relevant parts of Section Bpart 1 to 5and email this to your employee to complete Section Cpart 1 and 2 and Section D.
EMPLOYEE- Please email all completed sections to ,
For any enquiries, please contact Occupational Health on 98926 (internal) or 8344 0897.
Refer to the Occupational Health website for further information on occupational health issues:
CONFIDENTIALITY- All material collected on the HHAQ and any further medical examination remains confidential and filed securely in the Health & Safety Office
section B : supervisor completes
Please indicate (YES or NO) whether the work the employeewill be undertaking workthat involves any of the following staff activity hazards.
PArt 1. noise and/OR respiratory HAZARDS
Where noise and respiratory hazards are identified, supervisors must ensure that staff attends hearing and/or lung function testing by Occupational Health within 3 months of commencement, as required by the Occupational Health and Safety Act 2004 (Vic)and Occupational Health and Safety Regulations 2007 (Vic), s. 3.2.11.
Yes / High noise levels requiring hearing protection
Yes / Products causing lung irritants, for example: welding, epoxy resins, animal dander, dusts
PArt 2. SCHEDULED Hazardous substances
Supervisors must ensure chemical management training for their staff. Refer to Chemical risk management procedure.
Health Surveillance of staff using hazardous substances (listed below) is only required when they are actually exposed to these hazardous substances.
Will this employee work with any of the following chemicals? Yes(If yes, complete the following)
Inorganic ArsenicInorganic MercuryInorganic ChromiumInorganic LeadCadmium
ThalliumAcrylonitrile BenzeneIsocyanatesCreosote
Vinyl Chloride Crystalline SilicaPentachlorophenol Organophosphate Pesticides
4,4 Methylene bis (2-chloroaniline) (MOCA)Polycyclic aromatic hydrocarbons (PAH)
Will this employee work with any Prohibited and Restricted carcinogenic substances listed in Schedule 5Aor 5B(provide chemical name below)?
part 3. Microbial / Biological AGENTS
Yes / Do you work in childcare?
Yes / Do you work in healthcare?
Yes / Will the employee be exposed to the following animals for more than four hours per day, five days a week? Specify animals below:
Cats and dogs / Bats / Native fauna / Cattle, sheep and / or goats
Rats/mice / Primates / Horses / Poultry and other birds
Guinea pigs /rabbits / Pigs / Other Specify →
Yes / Do you visit an abattoir, or are you working with products from an abattoir?
Yes / Do you work with human tissue, blood, body fluidsor primary cell lines?
Yes / Do you work with rubbish collection, sewage, storm water or potentially contaminated waterways?
Yes / Other biological risks not previously mentioned. Specify →
part 4. EXTERNAL laserS
NOTE: Staff are required to have visual acuity checks before beginning, and after completing, external laser projects, as per the standard AS2211 Lasers. For appointments, contact University of Melbourne Eye Care.
Yes / Class 3B or Class 4 Laser. Specify →
part 5. supervisor’s signature
Supervisor’s name* / Telephone*
I confirm that the information I have provided in this form is an accurate reflection of the position requirements and that I am the Supervisor of this employee. / Signature of supervisor
(Level 1 delegation)*
Date
section C: to be completed by employee
part 1. employee information
Title* / Preferred name
Family name* / Given names*
Mobile
Email* / Date of birth*
Prospective employeesmay be required to attend a medical examination following assessment of the HHAQ.
For assistance in completing this form, please contact Occupational Health on 9035 5397 or 8344 4534.
Yes / Do you have known allergies to laboratory animal or other allergies that may affect your work
(ie: latex)? Specify →
PART 2. IMMUNISATION HISTORY
The table below indicates immunisation requirements associated with the particular occupation.Please fill in the relevant information below if you work in a Laboratory,with Animals,as a Healthcare or Childcare worker or working with sewage.
PLEASE NOTE: Vaccination requirements may vary based on individual exposures. Please contact the Occupational Health Nurse for advice on 8344 0897: If you require additional vaccinations other than the ones listed or if are in a role that may require vaccinations.
VACCINE PREVENTABLE DISEASE / WORK IN LABORATORY / WORK WITH ANIMALS / WORK IN HEALTHCARE / WORK IN CHILDCARE / OTHER
Relevant to laboratory staff working directly with human blood, bodily fluids, human cell lines, (Hep B) or human faecal and bowel tissue (Hep A) or those working with infectious agents including disposal or sterilisation. / This section does not apply to staffworking in laboratories with laboratory raised animals used in experiments
(eg. Rodents). / Working with sewage, storm water or potentially contaminated waterways.
Hepatitis A / Year of Last Vaccination: / If working with
non-human primates.
Year of Last Vaccination: / Year of Last Vaccination: / Year of Last Vaccination:
Recommended for early childcare only / Year of Last Vaccination:
Hepatitis B / Year of Last Vaccination: / If working with
non -human primates.
Year of Last Vaccination: / Year of Last Vaccination: / Year of Last Vaccination:
Diphtheria / Year of Last Vaccination: / If working with
non -human primates.
Year of Last Vaccination: / Year of Last Vaccination: / Year of Last Vaccination:
VACCINE PREVENTABLE DISEASE / WORK IN LABORATORY / WORK WITH ANIMALS / WORK IN HEALTHCARE / WORK IN CHILDCARE / OTHER
Chickenpox (Varicella) / Year of Last Vaccination: / If working with
non-human primates.
Year of Last Vaccination: / Year of Last Vaccination: / Year of Last Vaccination:
Measles, Mumps, Rubella (MMR) / Year of Last Vaccination: / If working with
non-human primates.
Year of Last Vaccination: / Year of Last Vaccination: / Year of Last Vaccination:
Whooping Cough
(Pertussis) / Year of Last Vaccination: / If working with
non-human primates.
Year of Last Vaccination: / Year of Last Vaccination: / Year of Last Vaccination:
TB test
(Mantoux) / Year of Last Test: / If working with
non-human primates.
Year of Last Test: / If working in an emergency clinical setting, respiratory ward, or with known TB patients
Year of Last Test: / If working in an emergency clinical setting, respiratory ward, or with known TB patients
Year of Last Test:
Poliomyelitis / Year of Last Vaccination: / If working with
Non-human primates.
Year of Last Vaccination:
Tetanus / Year of Last Vaccination:
Only if working with live bacterium or toxin / If working with
non -human primates.
Year of Last Vaccination: / Year of Last Vaccination:
Rabies/
Lyssavirus / Year of Last Vaccination: / Year of Last Vaccination:
Q-Fever / Year of Last Vaccination: / Year of Last Vaccination:
Employee declaration – Section D
employee agreement
1)I have read and understand the requirements of the supplied position description and where applicable the list of health hazards associated with the position as shown in Health and Hazard Assessment Questionnaire. / Yes No
2)Do you have any past or present medical condition, disorder, illness, injury, disease or disability which may:
- impact on your ability to undertake this position; and/or
- require special care or management? And/or
- be aggravated, exacerbated, recur or deteriorate due to performing this role?
Please be advised that the University may ask you to provide further information relating to your medical condition, disorder, illness, injury, disease, or disability in order for it to consider any reasonable adjustments to enable you to perform the role [and that such information may be provided to your relevant supervisor or manager for this purpose].
Please also note that under the Workplace Injury and Rehabilitation and Compensation Act 2013 (Vic), you are required to disclose all pre-existing injury and disease that you foresee could be affected by your performance of this role, and that failure to disclose such pre-existing injury and disease, or the making of a false or misleading disclosure, may disentitle you to compensation for any recurrence, aggravation, acceleration, exacerbation or deterioration of the pre-existing injury or disease arising out of, or in the course of, or due to the nature of your employment at the University.
I declare that the information I have provided in this form is to my knowledge, a true and accurate account of my past and present health. / Name*
Signature
Date*
PRIVACY STATEMENT
The University has collected personal information and health information about you in this form for purposes related to administering your employment at the University, and to ensure compliance with relevant laws, including workers’ compensation and equal opportunity laws. The University must comply with the Privacy and Data Protection Act 2014 (Vic) and the Health Records Act 2001 (Vic) when collecting, using or disclosing personal or health information. The University’s privacy policy can be found at and privacy queries may be directed to .
Employees please email this form with both sections completed in full to:
Refer to the Occupational Health website for more information about occupational health issues:
safety.unimelb.edu.au HR15 - Health and hazard assessment questionnaire (HHAQ)1 of 6
Date: March 2017 Version: 3.6 Authorised by: Associate Director, Health & Safety Next Review: March 2020
© The University of Melbourne – Uncontrolled when printed.