Worksafe Health Surveillance

WorkSafe Health Surveillance

Notification:MOCA

4,4’-methylene bis (2 chloroaniline)

Occupational Safety and Health Act 1984; Regulation 5.24
Confidential

Please complete all sections neatly. Incomplete forms will be returned.

A copy of laboratory report must be attached 

Return to :Occupational Physician, WorkSafe, Locked Bag 14, CLOISTERS SQUARE, PERTH WA 6850
Fax: 6251 2827 Tel: 1300 307 877 Email: /

1.EMPLOYER(Principal)

Company/Organisation name:
Site address:
Site Tel: / Site Fax: / Contact Name:

2. LABOUR HIRE (if worker is employed through Agency)

Company/Organisation name:
Address:
Tel: / Fax: / Contact Name:

3.EMPLOYEE / WORKER() all relevant boxes

Last name: / Given names:
Date of birth / Male / Female
Address:
Job Title: / Tel (h): / Mob:

4. WORKING WITH MOCA () all relevant boxes

New to MOCA work Worked with MOCA since (mm/yyyy)
Not new to MOCA work With current employer since (mm/yyyy)
Immediate previous employer (MOCA work) for years
MOCA industry () all relevant boxes
Polyurethane production
Other (specify) :

5.WORK ENVIRONMENT ASSESSMENT () all relevant boxes

Controls:
Wear gloves Yes No / Overalls/ Work Clothing Yes No
Respirator use Yes No / Laundering by employer Yes No
Process enclosed Yes No / Wash basins & showers Yes No
(hot & cold water)
Worker isolated from process Yes No / Smoking or Eating in workshop Yes No
Local exhaust ventilation Yes No / Dry sweeping Yes No
Shower & change into clean clothes at end of shift Yes No
Personal Hygiene
Smoker Ex- Smoker Non-Smoker Clean shaven Yes No

6.RISK ASSESSMENT (to be completed by the AMP) () all relevant boxes

Satisfactory Controls Yes No Not known
Satisfactory Personal Hygiene Yes No

7.BIOLOGICAL MONITORING RESULTS

Include previous two previous test results and attach copy of pathology laboratory results
Date / Urinary levels (µmol MOCA/ mol creatinine)
1. / // / Insert baseline or last known result in (1) and date
2. / // / Office use only:WISE ID:
TEST NO:
3. / //
4. / //

8. ACTIONS(by Appointed Medical Practitioner) () all relevant boxes

Counselled Employee
Informed Employer to review and implement controls in workplace.

9. RECOMMENDATIONS(by Appointed Medical Practitioner) () all relevant boxes

Suitable for MOCA work
Repeat urineMOCA test and questionnaire in weeks / months
Removal from exposure MOCA work
Medical examination by Medical Practitioner on //
Fit to resume work with MOCA from//
Referral for further tests (Specify)
Referral to Medical Specialist (specify)
Comment:

Appointed Medical Practitioner(responsible for supervising health surveillance)

Name: / Signature: Date: //
Tel: / Fax: / Contact Person:
Medical Practice
Address

For information or assistance, contact:
Occupational Physician or Occupational Health Nurse, WorkSafe : 93278777

MOCA Health Surveillance – WorkSafe WA - Notification form A1647713 08/05/2014Page 1 of2