Hazardous chemicals requiring health monitoring

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SECTION 2 – THIS SECTION TO BE RETAINED BY THE MEDICAL PRACTITIONER

PERSON CONDUCTING A BUSINESS OR UNDERTAKING

Company / Organisation name:

Site address:

Suburb:

Postcode:

Site Tel:

Site Fax:

Contact Name:

OTHER BUSINESSES OR UNDERTAKINGS ENGAGING THE WORKER

Company / Organisation name:

Site address:

Suburb:

Postcode:

Site Tel:

Site Fax:

Contact Name:

WORKER () all relevant boxes

Surname:

Given names:

Date of birth: DD/MM/YYYY Sex:

Male

Female

Pregnant/Breast Feeding?

Address:

Suburb:

Postcode:

Current Job:

Tel(H):

Mob:

Date started employment : DD/MM/YYYY

GENERAL HEALTH ASSESSMENT (if applicable)

Symptoms of:

Comments

Further testing?

Skin disorders

Yes No

Headaches, dizziness

Yes No

Respiratory tract

Yes No

Eyes

Yes No

Mucous membranes

Yes No

CNS

Yes No

Others

Yes No

Height _____cm

Weight _____kg

Bp ____/____ mmHg

Yes No

OTHER MEDICAL HISTORY, FAMILY MEDICAL HISTORY, CURRENT MEDICATION, COMMENTS, TESTS OR RECOMMENDATIONS (use separate sheet if necessary)

Medical Practitioner (responsible for supervising health monitoring)

Name:

Signature

Date: DD/MM/YYYY

Tel:

Fax:

Registration Number:

Medical Practice:

Address:

Suburb:

Postcode:

1 Source: http://esis.jrc.ec.europa.eu/index.php?PGM=cla.

1 ATSDR. 2001. Toxicological profile for Asbestos. Atlanta: Agency for Toxic Substances and Disease Registry www.atsdr.cdc.gov

2 Enhealth Dept Health and Ageing Environmental Health Risk Assessment www.health.gov.au

3 Australian Bureau of Statistics at www.ausstats.abs.gov.au

4De Klerk N, Henderson D, Jones M, Leigh J, Musk AW, Shilkin K, Williams V, ‘The diagnosis and attribution of asbestos-related diseases in an Australian context’, Adelaide Workshop on Asbestos-Related Diseases, J Occup Health Safety – Aust NZ, vol 18(5), pp 443-452, 2002.

5 http://www.mesothelioma-australia.com/home-page.aspx

1 Venables KM, Farrer N, Sharp L, Graneek BJ, Newman Taylor AJ, ‘Respiratory Symptoms Questionnaire for Asthma Epidemiology: Validity and Reproducibility’, Thorax, vol 48, pp 214-219, 1993.

2 The British Occupational Health Research Foundation (BOHRF), Guidelines for Prevention, Identification and Management of Occupational Asthma: Evidence Review and Recommendations, London 2004. www.bohrf.org.uk

1 The WorkCover NSW Biological Occupational Exposure Limit (BOEL) for benzene is 11.8 µmol S-PMA/mol creatinine in urine (which is equivalent to 25 μg/L in mass units), while the American Conference of Governmental Industrial Hygienists (ACGIH) biological exposure limits for benzene are 500 μg/g creatinine for tt-MA and 25 μg/g creatinine for S-PMA. WorkCover NSW BOEL and ACGIH biological exposure limit for S-PMA are about the same as there is approximately 1g creatinine/l urine.

2 Australian Government Department of Sustainability, Environment, Water, Population and Communities. www.environment.gov.au

1 Forced expiratory volume in one second

2 Forced vital capacity

3 Tiffeneau index

1 Venables KM, Farrer N, Sharp L, Graneek BJ, Newman Taylor AJ, ‘Respiratory Symptoms Questionnaire for Asthma Epidemiology: Validity and Reproducibility’, Thorax, vol 48, pp 214-219, 1993.

1 ACGIH Biological Exposure Indices 2007

2 Forced expiratory volume in one second

*^* Spirometry equipment should be calibrated regularly according to a standard protocol.

1 Forced expiratory volume in one second

2 Forced vital capacity

3 Tiffeneau index

1 Venables KM, Farrer N, Sharp L, Graneek BJ, Newman Taylor AJ, ‘Respiratory Symptoms Questionnaire for Asthma Epidemiology: Validity and Reproducibility’, Thorax, vol 48, pp 214-219, 1993.

*^*Spirometry equipment should be calibrated regularly according to a standard protocol.

1 Forced expiratory volume in one second

2 Forced vital capacity

3 Tiffeneau index

4 Venables KM, Farrer N, Sharp L, Graneek BJ, Newman Taylor AJ, ‘Respiratory Symptoms Questionnaire for Asthma Epidemiology: Validity and Reproducibility’, Thorax, vol 48, pp 214-219, 1993.

5 The British Occupational Health Research Foundation (BOHRF), Guidelines for Prevention, Identification and Management of Occupational Asthma: Evidence Review and Recommendations, London 2004. www.bohrf.org.uk

1 Wooller, KK (2003) Occupational Medicine Handbook (Eleventh Edition), Information for WorkCover Authority of NSW Authorised Medical Practitioners.

2 Table is reproduced from: Recommendations for Medical Management of Adult Lead Exposure, Michael J Kosnett, Richard P Wedeen, Stephen J Rothenberg, Karen L Hipkins, Barbara L Materna, Brian S Schwartz, Howard Hu, and Alan Woolf. Environmental Health Perspectives, Volume 115, Number 3, March 2007.

1 To convert μg/L to μmol mercury/mol creatinine multiply by MW creatinine = 113.12

MW mercury 200.59

For example 20 μg/L urine total mercury = 11.3 μmol mercury/mol creatinine.

2 The American Conference of Governmental Industrial Hygienists (ACGIH) recommended biological exposure index (BEI) for a pre-shift end of work week is 35 μg/g creatinine (= 20 μmol/mol creatinine). The WorkCover NSW Biological Occupational Exposure Limit (BOEL) Committee also recommends this value.

1 See ‘Biomarkers of Exposure and Effect’ in Section 2- Supplementary Information on MOCA - of this Guideline for further information.

2 BMGVs are not health based. They are practicable, achievable levels. A BMGV represents the 90th percentile of biological monitoring results from a representative sample of workplaces with good work hygiene practices. If a result is greater than the BMGV it does not necessarily mean that ill health will occur but does indicate that control of exposure may not be adequate.

0 The Australian Pesticides and Veterinary Medicines Authority (APVMA) is the national agency responsible for assessing and registering agricultural and veterinary chemical products and controlling them up to the point of retail sale. The States and Territories are responsible for control-of-use aspects, like licensing of pest control operators and aerial sprayers. All agricultural and veterinary chemical products containing approved active ingredients are required to bear approved labels stating what the active ingredient is and its percent concentration in that product.

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