Templates / Health and safety
Health surveillance referral record
Form · When a worker is referred, and when the outcome comes back
Records a worker sent for health surveillance because of their exposure (vibration, noise, dust, solvents, lead), and the fitness outcome. Medical details stay with the occupational health provider; this keeps only the outcome. Private to managers.
Use it in Sitro: add it to a project and fill it on a phone, free for 14 days.
The law and guidance behind it
- Control of Substances Hazardous to Health Regulations 2002 (COSHH), Regulation 11
- Control of Vibration at Work Regulations 2005, Regulation 7
- Control of Noise at Work Regulations 2005, Regulation 9
The questions
The worker
- Name
- Company
Referral
- Exposure
- Occupational health provider
- Date referred
Outcome (no medical details)
- Fitness
- Restrictions given (write "None" if none)
- Next surveillance due
Sign-off
- Recorded by
- Date and time
- Signature
A template to adapt to your site, not legal advice.
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