Remote HAVs and Skin Assessment

Please ensure that you have been asked to complete this page, and that your Manager is aware that you are sending this to us.

The contents of this form are sent directly to Aardvark’s Admin team, to be securely passed over to a Clinician for review. Your Employer will not see the contents of this form, only the result that is relevant for Occupational Health.

Please read the questions carefully and ensure you complete all sections as accurately and in as much detail as possible.

Data Protection 1998

All information supplied on this form may be held by Aardvark Occupational Health and used for the purpose required to process this assessment. It may be referred to an Occupational Health Clinician for further assessment.

View our Data Protection Policy

Date of birth(Required)

Manager's Name(Required)

Manager's Email(Required)

Email Address(Required)

What chemicals do you come into contact with at work?

Please summarise your exposure here: (e.g. Grinder for 1-2 hours a week, drill for 3-4 hours a week)

If your exposure is above the HSE action level of 2.5 m/s squared, please detail what level?

What jobs have you previously had with HAVs exposure?

How long were you in the job (roughly)?

Tingling, Pain & Numbness

Please provide any further detail if you have answered YES to any of the above(Required)

What jobs have you previously had with Skin exposure?

How long were you in the job (roughly)?

Please provide more detail if you have ticked any of the above

How long did it last?

If you don't wear PPE, but are exposed to Skin Sensitisers, why?

This field is for validation purposes and should be left unchanged.

Your mesage(Required)

Data Protection 1998

Employee Info

General Health

Hazards

Tingling, Pain & Numbness

White Finger

Musculoskeletal

Skin

Medical History

Skin Care Products

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