OHF 3b - Skin & Respiratory Health Surveillance Questionnaire



2548355Skin & Respiratory Health Surveillance Questionnaire - AssessmentThe?purpose of the questionnaire is to assess whether you have any health problems that may affect your ability to undertake the duties of your role and to ensure any exposure control measures in place are effective. OHS will make recommendations to the University regarding adjustments or modifications required to your role as a result of this assessment. SurnameStaff NumberFirst NameDate of BirthPreferred NameAgeWork EmailMobile / phoneJob TitleOccupationResearch staff / Technical staff / Undergraduate / Postgraduate / Academic Visitor / Other (please provide details): Line managerSchool safety adviserDepartmentPlace of workAnimal facility (if applicable)If you are not attending for a face to face appointment for respiratory lung function testing, you do not have to complete the remainder of this section : Move to Section 1 :Exposure StatusHeightWeightTo enable OHS to accurately calculate results for lung capacity we utilise predictions dependant on information about both birth gender and ethnicity: Gender at birthMale?Female?Are you pregnant?Yes?No?Ethnicity (please circle)Caucasian?African - American?North East Asian?South East Asian?Mixed / other?1. Exposure StatusDate and DetailsIf this is your first questionnaire, have you had any exposure to respiratory/skin sensitisers to date?If this is a subsequent questionnaire, have you had exposures since your last appointment?If you no longer work with respiratory/skin sensitisers when did you stop and why?If you are planning to cease exposures , please give details e.g. end of contract, or moving to another job2. Employment HistoryAt the University of EdinburghIn your careerHow long have you worked with respiratory/skin sensitisers? (E.g. animals, chemicals, dust, fumes, other substances – please provide as much detail as possible). Have you previously participated in a health surveillance programme? (please provide details)3. Current Work InformationWhich respiratory/skin sensitisers are you working with? – please list below (refer to COSHH risk assessment)List the chemicals / animals / materials you are currently working with:Frequency of exposure:(e.g. every day / week / month)Duration on each occasion:(e.g. xx hours every day / week / month)Description of work:What control measures are in place?(e.g. fume cupboard, LEV etc.)What personal protective equipment has been provided? (e.g. type of face mask, gloves, protective clothing) Type of gloves use:Type of facemask used (RPE):Has your RPE been ‘face fit’ tested?Yes ?No ?If no, please give reason: Face fit test date:Do you have a beard? (Beards are NOT compatible with close fitting RPE)Yes ?No ?Do you have any concerns regarding your RPE?(You must report concerns to your line manager)Yes ?Details:Have you reported concerns to your line manager?Yes ?No ?No ?4. Medical HistoryPlease answer all the following questions using (x). If ‘yes’ please give dates and details (including use of any medications / inhalers).Have you ever been affected by:YesNoDate and DetailsAsthma or any other breathing difficulties???Rhinitis / sinusitis / nasal issues???Conjunctivitis / eye issues???Hayfever???Eczema / dermatitis / skin issues???Allergies e.g. Latex / foods/ animals???Please list any additional medications 5. RespiratorySince your last appointment have you been affected recurrently by: (If ‘yes’ please give dates and details)YesNoDate and DetailsBlocked or running nose??Watery, itchy eyes??Bouts of coughing??Wheezing / difficulty in breathing??Chest tightness / shortness of breath??Had a cough lasting more than 4 weeks???Do you have any respiratory symptoms that tend to improve in periods when you are not at work? ??Do any of your symptoms get worse at night???6. SkinSince your last appointment have you experienced any of the following skin symptoms when working with skin irritants/sensitisers?(If ‘yes’ please give dates and details)YesNoDate and DetailsDo you experience any skin symptoms? (e.g. redness, itching and/or burning (tingling) sensation, rash or spots (hives) dryness (cracking / flaking).??If you have any of these symptoms do they tend to subside in periods where you are not working???Do you use moisturisers (if yes, how often and what type)?7. Social InformationYesNoDetailsDo you have any pets or contact with animals outside of work???Do you have any regular hobbies?(E.g. Bag Piping, diving, DIY, exercise)???Do you smoke???If yes how many per day?Are you an ex-smoker??If yes, when did you stop?8. DeclarationI certify that all the answers given above are true to the best of my knowledge and belief. I confirm I will notify occupational health if there are any changes to my respiratory or skin health between appointments and during this surveillance programme. SignedDatePlease return your completed form to Occupational.Health@ed.ac.ukPlease note that during the COVID 19 restrictions, following HSE guidance, health surveillance consists of paper screening only, lung function testing and face to face appointment will resume when appropriate. All employees have the right to access their Occupational Health records. Should you wish to do so, please speak to a member of the Occupational Health team for more details. This information is obtained for clinical use only.GDPR InformationThe information that you supply on this questionnaire will be held in confidence by the University Occupational Health Service as part of your occupational health record. Information regarding GDPR compliance can be found at this link OHS USE ONLYClinical notes:18821406337300ExaminationVisual Assessment of Hands: ScoreDetails0Skin looks normal1MildDry, redness, cracking, blisters, open sores, bleeding, infection23Moderate45SevereOther parts of the body:ScoreDetailsContraindications to carrying out Spirometry? Yes: NoSpirometry carried outSittingStandingAdvised to review COSHH risk assessment and RPE requirementsYesNoFurther information providedYesNoOHA / OHP review of health surveillanceYesNoOutcome: Please circle belowFIT FOR SPECIFIED WORKPAPER SCREEN ONLYEXPOSURE WITH PRECAUTIONUNFITRecall:OHL4 Issued – Notification of FitnessYesNoOH signature:Date: ................
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