Health and Safety

Executive

Control of Asbestos Regulations 2012 - Regulation 22(3)

 

Questionnaire - Respiratory Symptom - Non Licensed Work

Occupational information

*Does your work involve working with asbestos containing materials?

Respiratory symptoms

Have you ever, or since your last examination had:

• *an injury or operation affecting your chest?

• *pleurisy?

• *pulmonary tuberculosis?

*Do you usually cough during the day (or at night when on night work)?

*Do you usually bring up any phlegm from your chest on most days (or

nights) for as much as three months each year?

*Do you usually get short of breath when walking with people of your

own age on level ground?

*During the past three years, or since your last examination, have you had any chest illness which has kept you from your usual activities for as much as a week?

Did you bring up more phlegm than usual in any of these illnesses?

Smoking

*Have you ever smoked?

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Health and Safety

Executive

Control of Asbestos Regulations 2012 - Regulation 22(3)

Questionnaire - Respiratory Symptom - Non Licensed Work

Smoking

*Do you smoke at present?

*Have you given up smoking in the last month?

Ex Smokers

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Health and Safety

Executive

Control of Asbestos Regulations 2012 - Regulation 22(3)

Certificate of Medical Examination - Non-Licensed Work

 

Employer Details

(eg building name)

(eg street)

(eg district)

Employee Details

(eg building name)

(eg street)

(eg district)

and/or

Doctor Details

Use the Print/Save Form button below, not File > Print, to open the Form Summary window for printing.

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