HR 15
HEALTH AND HAZARD ASSESSMENT QUESTIONNAIRE (HHAQ)
SECTION A : SUPERVISOR COMPLETES ELECTRONICALLY
EMPLOYMENT / POSITION DETAILS / LOCATION
Employee name*
Department Name*
Building Number
Position title*
Duration of
employment
Level
Room
Position no.
From
To
Brief description of job responsibilities and role*
SUPERVISOR – Please click where staff activities may include any of the following;
☐ Wearing of hearing protection
☐ Working with lung irritants - See section B.1
☐ Working with scheduled hazardous substances – See section B.2
☐ Working in childcare
☐ Working in healthcare
☐ Working with animals – see section B.3
☐ Working in or visiting an abattoir
☐ Working in laboratories with human tissue, blood, body fluids, tissues, primary cell lines
☐ Working with infectious organisms
☐ Working in laboratories with bowel or faecal matter
☐ Working with sewerage, potentially contaminated water ways and rubbish collection
☐ Working with Class 3B or Class 4 lasers – see section B.4
SUPERVISOR - If you have clicked yes to any of the above please complete section B and email this to your employee to
complete section C and D. If you have not clicked any of the above email, complete section B.5 and forward to employee
to complete section C6 and D.
EMPLOYEE - Please email all completed sections to occupationalhealth-info@unimelb.edu.au,
For any enquiries, please contact Occupational Health on 9035 5397 or 8344 4534.
Refer to the Occupational Health website for further information on occupational health issues:
https://staff.unimelb.edu.au/health-safety-wellbeing/health-wellbeing
CONFIDENTIALITY - All material collected on the HHAQ and any further medical examination remains confidential and
filed securely in the office of Occupational Health.
OFFICE USE ONLY: OCCUPATIONAL HEALTH STAFF NOTES
☐ Nil
☐ Incomplete
☐ Occupational exposure
☐ 1st email
☐ 2nd email
☐ 3rd email
safety.unimelb.edu.au
HR15 - HEALTH AND HAZARD ASSESSMENT QUESTIONNAIRE (HHAQ) 1 of 6
Date: December 2015 Version: 1.1 Authorised by: Associate Director, Health & Safety Next Review: December 2018
© The University of Melbourne – Uncontrolled when printed.
SECTION B : SUPERVISOR COMPLETES ELECTRONICALLY
Please indicate (yes or no) whether the work the employee will be carrying out involves any of the following hazards, and
specify the nature of any potentially harmful substances or activities. For hazard assessment guidance, please refer to the
relevant procedure in OHS policy and procedures.
1. NOISE AND/OR RESPIRATORY HAZARDS
Where noise and respiratory hazards are identified, supervisors must ensure that staff attends hearing and/or lung function
testing by Occupational Health within 3 months of commencement, as required by the Occupational Health and Safety Act 2004
(Vic) and Occupational Health and Safety Regulations 2007 (Vic), s. 3.2.11.
☐ Yes ☐ No
High noise levels requiring hearing protection
☐ Yes ☐ No
Products causing lung irritants, for example: welding, epoxy resins, animal dander, dusts
☐ Yes ☐ No
Scuba diving (supervisor to ensure yearly medicals by authorised diving medical practitioner)
2. SCHEDULED HAZARDOUS SUBSTANCES
Supervisors must ensure chemical management training for their staff. Refer to Chemical risk management procedure.
Health Surveillance of staff or students using hazardous substances (listed below) is only required when they are actually
exposed to these hazardous substances.
Will this employee work with any of the following chemicals? ☐ Yes ☐ No (If yes, complete the following)
☐ Inorganic Arsenic
☐ Inorganic Mercury
☐ Thallium
☐ Acrylonitrile
☐ Vinyl Chloride
☐ Crystalline Silica
☐ 4,4 Methylene bis (2-chloroaniline) (MOCA)
☐ Inorganic Chromium
☐ Inorganic Lead
☐ Cadmium
☐ Benzene
☐ Isocyanates
☐ Creosote
☐ Pentachlorophenol
☐ Organophosphate Pesticides
☐ Polycyclic aromatic hydrocarbons (PAH)
Will this employee work with any Prohibited and Restricted carcinogenic substances listed in Schedule 5A or 5B (provide
chemical name below)?
Will the employee receive risk management training in the use of these substances?
☐ Yes
☐ No
Are appropriate controls in place to limit the risk of exposure?
• Yes
☐ - Further controls are not needed
• No
☐ - Contact local OH&S expert to review risk controls
• Unknown
☐ - Contact local OH&S expert to review risk controls
If no or unknown please advise:
safety.unimelb.edu.au
HR15 - HEALTH AND HAZARD ASSESSMENT QUESTIONNAIRE (HHAQ) 2 of 6
Date: December 2015 Version: 1.1 Authorised by: Associate Director, Health & Safety Next Review: December 2018
© The University of Melbourne – Uncontrolled when printed.
3. MICROBIAL / BIOLOGICAL AGENTS
☐ Yes
☐ No
Do you work in childcare?
☐ Yes
☐ No
Do you work in healthcare?
☐ Yes
☐ No
Will the employee be exposed to the following animals for more than five hours per week? Specify
animals below:
☐ Cats and dogs
☐ Bats
☐ Native fauna
☐ Cattle, sheep and / or goats
☐ Rats/mice
☐ Primates
☐ Horses
☐ Poultry and other birds
☐ Guinea pigs /rabbits
☐ Pigs
☐ Other Specify →
☐ Yes
☐ No
Do you visit an abattoir, or are you working with products from an abattoir?
☐ Yes
☐ No
Do you work with human tissue, blood, body fluids or primary cell lines?
☐ Yes
☐ No
Do you work with rubbish collection, sewerage, storm water or potentially contaminated
waterways?
☐ Yes
☐ No
Other biological risks not previously
mentioned. Specify →
Has the employee completed training in dealing with potential Infectious organisms that may arise in their employment?
☐ Yes
☐ No – Contact local OH&S Expert to review risk controls.
Refer to Biosafety and Occupational Health if further information is required.
4. EXTERNAL LASERS
NOTE: Staff are required to have visual acuity checks before beginning, and after completing, external laser projects, as
per the standard AS2211 Lasers. For appointments, contact University of Melbourne Eye Care.
☐ Yes
☐ No
Class 3B or Class 4 Laser. Specify →
5. SUPERVISOR’S SIGNATURE
Supervisor’s name*
Telephone*
Email
I confirm that the information I have
provided in this form is an accurate
reflection of the position requirements
and that I am the Supervisor of this
employee.
Signature of supervisor
or click yes to confirm
(Level 1 delegation)*
☐ Yes
Date
If sending fully electronic , please click
yes instead of signature
safety.unimelb.edu.au
HR15 - HEALTH AND HAZARD ASSESSMENT QUESTIONNAIRE (HHAQ) 3 of 6
Date: December 2015 Version: 1.1 Authorised by: Associate Director, Health & Safety Next Review: December 2018
© The University of Melbourne – Uncontrolled when printed.
SECTION C: TO BE COMPLETED BY EMPLOYEE ELECTRONICALLY
6. EMPLOYEE INFORMATION
Title*
Preferred name
Family name*
Given names*
Street address*
Suburb*
Country
State
Phone (AH)*
Mobile
Email*
Date of birth*
Postcode
Prospective employees may be required to attend a medical examination following assessment of the HHAQ.
For assistance in completing this form, please contact Occupational Health on 9035 5397 or 8344 4534.
☐ Yes
☐ No
Do you have known allergies to laboratory animal
or other allergies that may affect your work
(ie: latex)? Specify →
7. IMMUNISATION HISTORY
The table below indicates immunisation requirements associated with the particular occupation. Please fill in the
relevant information below if you work in a Laboratory, with Animals, as a Healthcare or Childcare worker.
PLEASE NOTE: Vaccination requirements may vary based on individual exposures. Please contact the Occupational
Health Nurse for advice on 8344 4534: If you require additional vaccinations other than the ones listed or if are in a role
that may require vaccinations.
WORK IN LABORATORY
WORK WITH ANIMALS
Relevant to laboratory
staff working directly
with vaccine preventable
diseases, human blood,
bodily fluids, human cell
lines, (Hepatitis B) and
human faecal and bowel
tissue (Hepatitis A and B).
This section does not
apply to staff working in
laboratories with
laboratory raised animals
used for the purpose of a
control in experiments
(eg. Rodents).
Year of Last Vaccination:
If working with primates.
Hepatitis A
HEALTHCARE
CHILDCARE
Year of Last Vaccination:
Year of Last Vaccination:
Year of Last Vaccination:
Year of Last Vaccination:
Year of Last Vaccination:
Year of Last Vaccination:
Year of Last Vaccination:
Year of Last Vaccination:
Hepatitis B
If working with primates.
Year of Last Vaccination:
Year of Last Vaccination:
Year of Last Vaccination:
Tetanus/Diphtheria
(ADT)
safety.unimelb.edu.au
HR15 - HEALTH AND HAZARD ASSESSMENT QUESTIONNAIRE (HHAQ) 4 of 6
Date: December 2015 Version: 1.1 Authorised by: Associate Director, Health & Safety Next Review: December 2018
© The University of Melbourne – Uncontrolled when printed.
WORK IN LABORATORY
WORK WITH ANIMALS
HEALTHCARE
CHILDCARE
Year of Last Vaccination:
Year of Last Vaccination:
Year of Last Vaccination:
Year of Last Vaccination:
If working with children,
severely immune
compromised patients or
in emergency care.
Year of Last Vaccination:
Chickenpox
(Varicella)
Measles, Mumps,
Rubella (MMR)
Year of Last Vaccination:
If working with children,
severely immune
compromised patients or
in emergency care.
Year of Last Vaccination:
Whooping Cough
(Pertussis)
Year of Last Vaccination:
Year of Last Vaccination:
TB test
(Mantoux)
If working in an emergency
clinical setting, respiratory
ward, or with known TB
patients
If working in an emergency
clinical setting, respiratory
ward, or with known TB
patients
Year of Last Test:
Year of Last Test:
Year of Last Vaccination:
Rabies/Lyssavirus
Year of Last Vaccination:
Q-Fever
safety.unimelb.edu.au
HR15 - HEALTH AND HAZARD ASSESSMENT QUESTIONNAIRE (HHAQ) 5 of 6
Date: December 2015 Version: 1.1 Authorised by: Associate Director, Health & Safety Next Review: December 2018
© The University of Melbourne – Uncontrolled when printed.
EMPLOYEE DECLARATION – SECTION D
EMPLOYEE AGREEMENT
1) I have read and understand the requirements of the supplied position description
and where applicable the list of health hazards associated with the position as
shown in Health and Hazard Assessment Questionnaire.
☐ Yes
☐ No
2) Do you have any past or present medical condition, disorder, illness, injury, disease
or disability which may:
☐ Yes
☐ No

impact on your ability to undertake this position; and/or


require special care or management? And/or
be aggravated, exacerbated, recur or deteriorate due to performing this role?
If yes, please provide further details below, along with suggestions for any reasonable
adjustments that the university should consider, in order to enable you to perform the role:
Please be advised that the University may ask you to provide further information relating to your medical condition,
disorder, illness, injury, disease, or disability in order for it to consider any reasonable adjustments to enable you to
perform the role [and that such information may be provided to your relevant supervisor or manager for this purpose].
Please also note that under the Workplace Injury and Rehabilitation and Compensation Act 2013 (Vic), you are required
to disclose all pre-existing injury and disease that you foresee could be affected by your performance of this role, and
that failure to disclose such pre-existing injury and disease, or the making of a false or misleading disclosure, may
disentitle you to compensation for any recurrence, aggravation, acceleration, exacerbation or deterioration of the preexisting injury or disease arising out of, or in the course of, or due to the nature of your employment at the University.
I declare that the information I have
provided in this form is to my knowledge,
a true and accurate account of my past
and present health.
Name*
Signature
Date*
PRIVACY STATEMENT
The University has collected personal information and health information about you in this form for purposes related to
administering your employment at the University, and to ensure compliance with relevant laws, including workers’
compensation and equal opportunity laws. The University must comply with the Privacy and Data Protection Act 2014
(Vic) and the Health Records Act 2001 (Vic) when collecting, using or disclosing personal or health information. The
University’s privacy policy can be found at http://policy.unimelb.edu.au/MPF1104 and privacy queries may be directed
to privacy-officer@unimelb.edu.au.
Employees please email this form with both sections completed in full to:
occupationalhealth-info@unimelb.edu.au
Refer to the Occupational Health website for more information about occupational health issues:
https://staff.unimelb.edu.au/health-safety-wellbeing/health-wellbeing
safety.unimelb.edu.au
HR15 - HEALTH AND HAZARD ASSESSMENT QUESTIONNAIRE (HHAQ) 6 of 6
Date: December 2015 Version: 1.1 Authorised by: Associate Director, Health & Safety Next Review: December 2018
© The University of Melbourne – Uncontrolled when printed.