Health Monitoring Identification
Form
This form is to be completed by all Organisational Units (OUs) within the University of Tasmania.
The head of the OU or delegate in consultation with the relevant Health and Safety Representative (HSR)
is to complete this form and review on an annual basis.
For further information please refer to the University Health Monitoring Minimum Standard.
Organisational Unit
Location
OU head or delegate
HSR
Period
Current
review
Previous
review
IDENTIFICATION OF HAZARDS REQUIRING HEALTH MONITORING
Identify those activities undertaken within the Organisational Unit that could pose a potential health hazard
to workers and students and that can be monitored.
Describe each hazard and its exposure route, assess the risk and list the applicable monitoring requirements.
Health Concern
Hazard(s)
Hazardous chemicals
Review with the Hazardous
Chemicals Health Monitoring
Requirement Checklist
Noise and hearing
Audiometric testing must be
provided for a worker who is
required to frequently use personal
hearing protectors as a control
measure for noise that exceeds the
exposure standard
For work with risk group 3 and 4
human pathogens – refer to AS
2243.3 for more details.
Microbiological
Asbestos
Manual handling
Risk
Rating
Monitoring Requirements
Not for undertaking licenced
removal but for potential exposure
during other work such as
maintenance or due to building
issues.
As covered in the Hazardous
Manual Tasks Code of Practice
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Health Monitoring Identification
Form
Action Plan
List those actions which are to be undertaken in implementing the required monitoring program for the
Organisational Unit.
Action
Responsibility Due date
Status
1. Workers and or HSRs are consulted in the identification of health hazards
☐Yes ☐No
☐N/A
2. Safe Work Procedures are in place for identified health hazards
☐Yes ☐No
☐N/A
3. Plant and equipment used to eliminate or minimise exposure is maintained
☐Yes ☐No
☐N/A
4. Workers are aware of health monitoring needs
☐Yes ☐No
☐N/A
5. Students are aware of health monitoring needs
☐Yes ☐No
☐N/A
6. Trends from surveillance outcomes are reported to management
☐Yes ☐No
☐N/A
OU head or
delegate name:
Signature:
Date:
HSR name:
Signature:
Date:
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