A registered medical practitioner will complete this report if your worker is exposed to a specific hazardous substance which may present a health risk to them.
If the report finds that the worker must not have any further contact with the hazardous substances for any period of time, you must notify WorkSafe.
Specific hazardous substances which you need to report are listed in column 1 of schedule 3 in the NOHSC National Model Regulations for the Control of Workplace Hazardous Substances. WorkSafe may determine further hazardous substances which require a health surveillance report, there will be published in the Government Gazette.
What you need to do
The employer must complete section 2 of the form, and supply it to the doctor before health surveillance is provided.