ELECTROMAGNETIC FIELDS (EMF)
HEALTH SCREENING FORM

The University has a legal responsibility safely to manage all work, to provide a safe and healthy workplace and to ensure that all systems of work are safe. Under certain legislation it is legally obliged to monitor the health of persons working with potentially hazardous materials. This form enables the University to fulfil its duties and to ensure training has been received. No person is permitted to work with specified potentially hazardous materials until they have received, or are receiving, adequate training (whether in this University or elsewhere) and a Risk Assessment has been completed.

Health surveillance is a requirement for all of the listed schemes of work. Unless a correctly completed form is returned to Occupational Health, approval for your registration and permission to work will not be given.

Employee Full Name:	…………………………………………………………

Statement by SUPERVISOR (where applicable)

An examination of competence has been carried out satisfactorily

Supervisor’s name	…………………………………………………………

Supervisor’s signature	…………………………………………………………

Has a risk assessment been completed?	Y	N

Has the Containment Level been identified?	Y	N

SECTION 2:
OCCUPATIONAL HEALTH SERVICE

UNIVERSITY OF ESSEX

HEALTH SCREENING RECORD

PRIVATE AND CONFIDENTIAL

This form is confidential to Occupational Health. Once completed, please return to ohquery@essex.ac.uk or by post to Occupational Health, Room 4N.6.2, University of Essex, Wivenhoe Park, Colchester, Essex CO4 3SQ

All staff who will be involved in laboratory work with electromagnetic fields (EMF), must complete health screening before beginning this work. The aim is to identify anyone who may be at particular risk from exposure to non-ionising radiation. If an Occupational Health Advisor considers specific precautions or support measures are required to ensure your safety, we will advise your manager of these, after discussion with you. Information on any underlying health issue will not be divulged unless you request this. Whilst you continue in such work, you must inform the OH Service if: You are involved in any incident where you may be accidentally exposed to EMF you work with You develop symptoms that might be caused by exposed to EMF you work with You develop any health condition which may increase your risk of exposure to EMF Data Protection information The information that you supply on this questionnaire will be held in confidence by the Occupational Health Service as part of your occupational health record. You can obtain access to your record by contacting the Occupational Health Service on 01206 872399, or contacting us at the email address above.

Your details
Title:	Full name:
Department/Faculty/Section/School:	Date of birth:
Job title:	Contact telephone number:
Essex email address:	Room number:
Start date:	End date:
Current residential address:	GP name, address and telephone number:

Medical Information
Exposure to EMF can interfere with the normal operation of medical devices causing them to malfunction or cause injuries. Please answer yes/no as to whether you have any of the following (if yes, please provide details at the bottom in the box provided)
Cardiac pacemaker	Yes / No	Orthopedic implants or joints	Yes / No
Implantable cardiac defibrillator	Yes / No	Pins / plates / screws	Yes / No
Cochlea implants (inner ear)	Yes / No	Surgical staples and slips (eg. Tubal ligation clips used in female sterilization and aneurism clips)	Yes / No
Brainstem implant (eg. Shunt)	Yes / No	Stents	Yes / No
Neurostimulator	Yes / No	Heart valve prosthesis	Yes / No
Implanted drug infusion pump	Yes / No	Annuloplasty rings	Yes / No
Intrauterine contraceptive device (IUD)	Yes / No	Hormone infusion pumps	Yes / No
Penile implants (used to treat erectile dysfunction)	Yes / No	Hearing aids	Yes / No
Dental fillings and/or bridges	Yes / No	Continuous glucose monitoring	Yes / No
Insulin pumps	Yes / No	Metalized drug delivery (over the counter or prescription)	Yes / No
Metallic fragments in or near eyes (common in welders/metal workers/military injuries)	Yes / No	Jewellery or piercings	Yes / No
Semi-permanent make up	Yes / No	Body art / tattoos (some tattoo ink contains traces of metal)	Yes / No
Further details (if answered yes to any of the above)

Declaration
I have answered all questions to the best of my knowledge. I agree to inform the Occupational Health Service of any significant change in my health status whilst involved in work with risk of exposure to infections agents Signed: ______________________________________________ Date: ___________________________ Print name: __________________________________________

For OH use only
Date received: _____________________________ Notification: Fit / Review / Not Fit (delete as applicable) Signed: ________________________________________ Date:___________________________ Print name: ____________________________________