HAVS Health Surveillance Form
Record worker details, vibration exposure, hand-arm symptoms, and follow-up actions for health surveillance.
Worker and Job Details
Worker's Full Name
*
First Name
Last Name
Job Title / Role
*
Department / Site / Location
*
Supervisor Name
First Name
Last Name
Exposure and Symptom Screening
Primary tool or equipment used
*
Pneumatic drill
Breaker/Jackhammer
Grinder
Chainsaw
Hammer drill
Sander/Polisher
Leaf blower
Other
Average vibration exposure frequency or duration
*
Please Select
Less than 1 hour per day
1 to 2 hours per day
2 to 4 hours per day
More than 4 hours per day
Occasional use only
Other
Currently experiencing hand or arm symptoms
*
Yes
No
If yes, describe the symptoms
Do the symptoms interfere with work or daily tasks
*
Yes
No
Health Surveillance Outcome and Follow-up
Health surveillance outcome
*
Fit for work
Monitor and repeat surveillance
Refer to occupational health
Remove from vibration exposure pending review
Other
Reviewer notes or recommendations
Submit
Should be Empty: