Medical Certification to
Work in a Laboratory,
Workshop and Studio
Return completed forms to:
Work Health and Safety
University of Tasmania
Private Bag 46
Hobart Tas 7001
(For any queries, contact the Manager of :
WHS on 6226 7555)
To work in a University laboratory or workshop a medical declaration must be completed. If a person
answers “yes” to any of the questions below, they must obtain medical certification from their doctor.
 Are you aware of any medical condition or other condition that may affect your capacity to participate
in laboratory or workshop activities?
 Are you currently taking any medication/substances that may affect mental alertness and/or coordination?
 Have you suffered seizures, fits, convulsions, epilepsy, blackouts, fainting, double vision, sleep
disorders, sleep apnoea or narcolepsy within the last 5 years?
PERSON SEEKING MEDICAL CERTIFICATION:
Full Name:
Organisational Unit:
Date of Birth:
Contact Number:
Campus:
Course name:
Student Number: or
_______________
Worker Number:
/
Course Coordinator/Supervisor, and Contact No:
_______________
Ext.
___________
DOCTOR CERTIFICATION:
I, Dr
of
_______
(surgery name or address)
(full name)
being the treating doctor of:
declare them:

____
_____________________________________________________________
(patient name)
Medically fit
or

Medically unfit
to undertake all laboratory or workshop activities, based on an assessment of their medical condition and
any drugs they may be prescribed to take. If the person gives consent, please specify details below:
Medical condition(s):
 N/A – no known/diagnosed medical condition; or
 Specify details:
Medication:
 N/A – not taking/prescribed any medication; or
 Specify details:
List any special requirements/restrictions that apply as part of this consent (if any):
Doctor’s Signature: .................................................................... Date: .........................................
Surgery Stamp: