The Elevator Company Ltd

Occupational Health surveillance

Health Surveillance Questionnaire to be completed during appraisal Yes No

1. Control of Has your manager completed a COSHH assessment?
Substance
Hazardous to Does your work expose you to substances hazardous to
Health health such as skin/respiratory irritants?
(COSHH)
Have you had a lung function test (spirometry) in the last
12 months?

Are your immunisations up to date?

2. Skin Have you experienced any skin problems which are likely
to link to your work?
3. Hand Arm Do you use hand held vibrating tools? E.g. drills ect?
Vibration
Syndrome If yes, have you experienced numbness, tingling or loss of
(HAVS) sensation in your fingertips in the last 12 months?
4. Work Have you experienced work related stress in the last 12
Related Stress months?
5. Lone Worker Do you undertake lone working? (If yes, manager should
perform a lone worker risk assessment)
6. Moving & Do you have any musculoskeletal injury that affects your
Handling ability to do your job role?
7. Vision Test Have you had a vision test in the last 2 years?
8. Ergonomics Do you use DSE for more than 4 hours a day? (If you do
Display Screen then have you completed a DSE self-assessment form in
Equipment the last 2 years)
(DSE)
9. Health in This there any underlying medical conditions you feel
General management should be made aware of?

Staff name & signature………………………..…………………………………………………….

Job description ……………………………..……………………………………………...………..

Managers signature …………………………… Date……….………………………..