Asbestos health surveillance forms - Queensland Government

At least 3 technically acceptable manoeuvres should be obtained with the
highest and second highest FEV1 and FVC within 0.2L 2 .
Use best result for FEV1 and FVC, even if from different tests.
FEV 1
FVC
FEV 1 /FVC%
Normal Abnormal
% Predicted
Comments: __________________________________________________________
____________________________________________________________________
Recommendations
Review work practices Yes No
Remove from exposure Yes No
Employer contacted Yes No
Follow-up medical examination on: ___________________________
Other comments: ______________________________________________________
____________________________________________________________________
A health monitoring report is prepared by the registered medical practitioner
and given to the employer. The employer must give a copy to the worker.
Doctor’s name: ___________________________ (please use block letters or practice stamp)
Address: ____________________________________________________________
____________________________________________________________________
Telephone: _____________________________
Signature: __________________________________ Date / /
2
Pierce R and Johns D. The measurement and interpretation of ventilatory function in clinical practice. National Asthma
Campaign, viewed at www.nationalasthma.org.au
© The State of Queensland (Department of Justice and Attorney-General) 2011
Copyright protects this document. The State of Queensland has no objection to this material being reproduced, but asserts its right to be recognised
as author of the original material and the right to have the material unaltered. The material presented in this publication is distributed by the
Queensland Government as an information source only. The State of Queensland makes no statements, representations, or warranties about the
accuracy or completeness of the information contained in this publication, and the reader should not rely on it. The Queensland Government disclaims
all responsibility and all liability (including, without limitation, liability in negligence) for all expenses, losses, damages and costs you might incur as a
result of the information being inaccurate or incomplete in any way, and for any reason.
Workplace Health and Safety Queensland, Department of Justice and Attorney-General
Asbestos - health monitoring forms
PN 10445 Version 2. Last updated June 2012.