Asbestos health surveillance forms - Queensland Government
Asbestos health surveillance forms - Queensland Government
Asbestos health surveillance forms - Queensland Government
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Work tasks/ environment<br />
Questions about previous work<br />
Before this work, did you work in any other dusty environment or in a job with exposure<br />
to asbestos?<br />
Yes<br />
No<br />
List all the jobs you have had since leaving school.<br />
Occupational history<br />
Dates of service<br />
(e.g. 2000-2004)<br />
Employer and occupation(s)<br />
Note any exposures to dust,<br />
fibres, mists, fumes,<br />
chemicals<br />
Questions about present work<br />
How many years have you worked at your present work?<br />
How many days per week do you usually work?<br />
How many hours per day do you usually work?<br />
In what types of work/tasks are you exposed to asbestos?<br />
___________________________________________<br />
___________________________________________<br />
___________________________________________<br />
___________________________________________<br />
______ years<br />
______ days<br />
______ hours<br />
Hours worked per week<br />
_________<br />
_________<br />
_________<br />
_________<br />
Workplace Health and Safety <strong>Queensland</strong>, Department of Justice and Attorney-General<br />
<strong>Asbestos</strong> - <strong>health</strong> monitoring <strong>forms</strong><br />
PN 10445 Version 2. Last updated June 2012.
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