Health monitoring application form - Queensland Government
Health monitoring application form - Queensland Government
Health monitoring application form - Queensland Government
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<strong>Health</strong> <strong>monitoring</strong> <strong>application</strong> <strong>form</strong>(Completed by medical practitioners to be added to the Workplace <strong>Health</strong> and Safety <strong>Queensland</strong>list of medical practitioners who do health <strong>monitoring</strong>)Lodging the <strong>application</strong>Post:Ms Karin ShepherdOccupational <strong>Health</strong> BranchWorkplace <strong>Health</strong> and Safety <strong>Queensland</strong>Department of Justice and Attorney-GeneralGPO Box 69Brisbane Qld 4001Fax: 07 3237 0229Scan and email: karin.shepherd@justice.qld.gov.auI have read the workplace health <strong>monitoring</strong> guidelines and <strong>form</strong>s provided on the Workplace<strong>Health</strong> and Safety <strong>Queensland</strong> website for: Acrylonitrile 4,4’Methylenebis (2-chloroaniline)(MOCA) Asbestos Inorganic mercury Benzene Isocyanates Cadmium Methyl bromide Creosote Organophosphate pesticides Crystalline silica Pentachlorophenol (PCP) Inorganic arsenic Polycyclic aromatic hydrocarbons (PAH) Inorganic chromium Thallium Fluoride Vinyl chloride Herbicides All Inorganic leadI agree to my name being included in a list of medical practitioners who do health<strong>monitoring</strong> which is made available to industry.I do not agree.(details continue over page)
Doctor’s name: ______________________________________________Signature: __________________________________________________ Date: / /Email: _____________________________________________________Practice contact details: (please use block letters or practice stamp)Place practice stamp herePractice name: __________________________________Address: _______________________________________Phone and fax: __________________________________Workplace <strong>Health</strong> and Safety <strong>Queensland</strong> www.worksafe.qld.gov.au 1300 369 915The material presented in this publication is distributed by the <strong>Queensland</strong> <strong>Government</strong> for in<strong>form</strong>ation only and is subject to change without notice. The<strong>Queensland</strong> <strong>Government</strong> disclaims all responsibility and liability (including liability in negligence) for all expenses, losses, damages and costs incurred asa result of the in<strong>form</strong>ation being inaccurate or incomplete in any way and for any reason.© State of <strong>Queensland</strong> (Department of Justice and Attorney-General) 2013PN10812 Version 3 Last updated October 2013 - <strong>Health</strong> <strong>monitoring</strong> <strong>application</strong> <strong>form</strong> PN10812 Version 3 Last updated October 2013 – <strong>Health</strong> <strong>monitoring</strong> <strong>application</strong> <strong>form</strong> 2
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