Hazardous substance health monitoring report

A form to complete if a worker is exposed to a specific hazardous substance which may present a health risk to them.
Last updated

Feb 2020

Reading level


File type and size

PDF, 113.62 kB

Document length

3 pages

What it contains

The employer must complete section 2 of the form, and supply it to the doctor before health surveillance is provided.

The doctor will assess the worker for adverse affects, check test/examination results and certify the employee's fitness to work with the hazardous substances.

If the doctor recommends the worker is removed from working with the hazardous substance, then you must notify WorkSafe by submitting this report.