HAVS Screening Form
Please complete this form to help assess your risk for hand-arm vibration syndrome (HAVS).
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Occupation/Job Title
*
How many years have you used vibrating tools or machinery?
*
Average daily use of vibrating tools/machinery
*
Please Select
Less than 1 hour
1–2 hours
2–4 hours
More than 4 hours
Have you experienced any of the following symptoms in your hands or fingers? (Select all that apply)
*
Tingling or numbness
Blanching (whitening) of fingers
Loss of grip strength
Pain or discomfort
None of the above
Do your symptoms worsen during cold or damp weather?
*
Yes
No
Do you use any of the following protective measures at work? (Select all that apply)
*
Anti-vibration gloves
Regular breaks
Tool maintenance
Job rotation
None of the above
Have you previously reported any hand or arm symptoms to your employer?
*
Yes
No
Please describe any other relevant information about your hand or arm condition or exposure (optional)
Submit
Should be Empty: