Medical Protocols,

Procedures
&
Standards

Page 1 of 61
H,S&EP Document/26003/Issue 3/March 2010

CONTENTS
1

Introduction to Occupational Health Procedure & Standards

Definitions and other Relevant Information

The Health Professionals

Suitability of Individuals for Work

Pre-placement Questionnaires

A Health Screening Programme

The Medical Protocol

Procedure and Standards

Body Mass Index (BMI)

10

Vision

11

Hearing

12

Lung Function

13

Blood Pressure

14

Urinalysis

15

Venapuncture

16

Musculoskeletal Assessment

17

Skin Assessment

18

Assessment of Hand Arm Vibration Syndrome (HAVS)

19

Drug Alcohol Testing

20

Cholesterol Testing

21

Health Promotion

22

Job Types & Health Surveillance Needs

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UK Contractors Group
OCCUPATIONAL HEALTH PROCEDURE & STANDARDS
1.

INTRODUCTION

UK Contractors Group Companies are, generally, the larger contractors who already have
in place an Occupational Health infrastructure. This can be made up of an internal in
company facility or an external service provider. In both cases doctors, occupational
health managers and nurses will already be undertaking the activities referred to in this
document. It should be noted that whilst this document deals with many technical issues,
its over-arching aim is to ensure the wellbeing of the workforce by monitoring the effect of
work on the individual and the likely impact of the individual on the work process
Whilst the UK Contractors Group (through the now defunct Major Contractors Group)
contributed to the drafting of the Constructing Better Health document, it was felt that
because MCG Companies already had structures in place, associated with this subject,
that a simplified document was required for UKCG Companies use. This is not intended to
undermine CBH but rather that parallel arrangements, relating to the larger contractors
existing occupational health arrangements, are produced. It is recognised that continuity
between the two approaches to this subject is important, as many of the contractors
supply chain partners, in time, will be likely to use CBH as their occupational health
provider.
The general objectives of this document are therefore clarity, simplicity and a defining of
standards for medical protocols and reporting procedures. It should be noted that these
are minimum standards and companies are free to do more and set higher standards than
this document requires. It is also the intention of the writers that this document be used in
a sensible manner and therefore logical, appropriate, balanced, effective and proportional
are all watchwords that should be applied. In other words simply using this document in a
painting by numbers manner is not an option. For example, a plant operator using a
remotely controlled roller on a green field site may not require the same level of health

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surveillance as a tower crane driver working in a difference environment: it is for the

management to decide what is appropriate in the circumstances.
One of the reasons for the UKCGs past successes in health & safety is its ability to
encourage contractors to act together. This document attempts to build on this platform in
terms of medical practice, equipment used and reporting format. However, it should be
noted that UK Contractors are strongest when they work together and the sentence above
concerning minimum standards is not intended to be a licence to enable everyone to do
their own thing.
Reporting is often seen as the poor relation in this respect, but by standardising the
method of reporting/types & units of measurement, UK Contractors Group Companies may
be able to share information in the future, where this is appropriate. The focus for health
surveillance should, in our view, be safety critical workers. (This term is defined in the
next section). However, this should not prevent the health screening of other workers
taking place where the organisation concerned thinks that it is appropriate
Where contractors attempt to transfer occupational health information from one to another,
it is essential that this has the approval of the person(s) concerned and that it takes the
form of a simple, fit for work declaration. This must relate of course to the work that the
person is expected to do and therefore can be qualified in this respect.

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2.

DEFINITIONS
Occupational Health

Occupational Health is a multidisciplinary subject. It encompasses medicine, nursing,

occupational hygiene, ergonomics, toxicology.
Occupational health can be conveniently divided into two main components:-

The effects of work on health (e.g., the effects of dusts on the lungs, irritants on the
skin).

The effects of health on work (fitness to work, e.g. good vision for drivers, how to
accommodate the diabetic or epileptic if they work at heights or in isolation).

Relevant Legislation
There is a wealth of current health and safety legislation, which directs and drives good
Occupational Health Practice, usually in conjunction with Safety Management. The Health
and Safety at Work Act requires employers to take account of the needs of their
employees in terms of health, safety and welfare. It places duties on the employer and
employees to set and achieve acceptable and reasonable standards of practice, so far as
is reasonably practicable.
Additional Legislation
Additional legislation such as the Control of Substances Hazardous to Health and the
Management of Health and Safety at Work Regulations require health surveillance to be
carried out where the health of employees could be at risk from the work they do which
may include exposure to substances hazardous to health.
This situation is mirrored in the very specific Control of Lead at Work Regulations, the
Control of Asbestos at Work Regulations and the Ionising Radiations Regulations.
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Health and Safety speaks in terms of Hazard, Risk and Control Measures. In the
occupational health world these terms could mean:
Hazard
Is the possible adverse effect on health, following exposure to a substance or activity, e.g.
exposure to dust containing silica may result in silicosis, exposure to wet concrete may
result in dermatitis, and poor ergonomics at a VDU workstation may result in
musculoskeletal problems.
Risk and Control Measures
Risk is a means of measuring the potential for a substance or activity to cause harm and
varies according to the nature of the hazard and the number of persons likely to be
involved. There are various risk measurement techniques although this is not a precise
science and High medium and low are perfectly satisfactory. All these measures do is
flag up the amount of effort (control measures) required to bring the level of possible harm
down to zero or low. Whilst it is easier to assess the hazard before any control measures
are taken the degree to which it is already controlled, e.g., dust exposure may be
controlled at source, i.e. removed by appropriate ventilation should be taken into account.
Personal protective equipment such as respirators and goggles may provide immediate
protection to the individual from the working environment, although this is not as desirable
as control at source. The need to design out the problem rather than simply providing
PPE is much higher up the Principles of Prevention which are themselves a legal
requirement under the Management of Health and Safety at Work Regulations. Again, the
aim is to take suitable and sufficient measures to reduce the risk to zero or low starting
with the need to reduce the risk in the first place and only providing PPE as a solution
when all other avenues have been exhausted.

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In many situations within the workplace, control measures cannot be regarded as absolute
and there may be a need for health surveillance, the purpose of which is to:

Identify early health problems before they cause significant morbidity

To check the control measure are working adequately

Health surveillance takes various forms depending upon the nature of the hazard and the
techniques available, e.g., exposure to noise may result in noise-induced deafness.
Audiometry tests hearing and gives an indication of whether or not an employee is
beginning to suffer from early signs or even later more significant signs of noise-related
deafness.
Safety Critical Workers
These are individuals whose ill health, mental or physical condition, may in the course of
their work, compromise or pose a significant risk to the health and safety of either
themselves or others. Plant operators would be an example of persons in this group,
where the nature of their occupation and their ability to place others at risk places them in
the safety critical section.
Similarly, a workers specific working environment could place them in the high risk group.
Persons who work in confined spaces, compressed air, on the railways or in motorway
traffic management could also be deemed to be safety critical.
3.

THE HEALTH PROFESSIONALS

The Management of Health and Safety at Work Regulations (MHSW) state that, where
risk assessment identifies circumstances where health surveillance is required employees
must have access to an appropriately qualified practitioner for advice on surveillance.
Therefore employers who appoint doctors, nurses or other health professionals to advise
them of the effects of work on employee health, or to carry out certain procedures, for
example, health surveillance, should first check that the providers can offer evidence of
sufficient level of expertise or training in occupational health.
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This is reinforced by the Health Surveillance at Work Guidance (HSG 61, HSE Books)
which states that it is the duty of the employer to provide health surveillance for those
employees considered at risk and that it is essential that the people who carry out health
surveillance are competent to do so. The level of competence required will depend on the
tasks performed and specific standards can be found within guidance associated with
regulations.
When appointing either an occupational doctor or an occupational health nurse, their
registration/personal identification number (PIN) should be obtained and confirmed with
the appropriate governing body.
For doctors, the General Medical Council (GMC) website (www.gmc-org.uk) will provide
information relating to the individuals registration and fitness to practice and the Faculty of
Occupational Medicine (FOM), (www.facoccmed.ac.uk) will be able to confirm their
occupational health qualification. For nurses, the Nursing and Midwifery Council (NMC)
website, (www.nmc-uk.org), will allow you to confirm the individuals registration and
qualification details.

Occupational Health Doctors

Occupational Health Doctors are required by law to possess skills and expertise including
an understanding of the health hazards which can arise at work, the ability to assess risks
relating to the health of individuals and groups, knowledge of the law relating to workplace
issues and awareness and understanding of the way business operates.
There are currently three levels of qualification in Occupational Medicine for Doctors:

The Diploma in Occupational Medicine (D.Occ.Med.)

The Associateship of the Faculty of Occupational Medicine (AFOM)

Membership of the Faculty (MFOM).

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In addition, the Fellowship of the Faculty (FFOM) is awarded to those occupational

physicians with MFOM who have made a distinguished contribution to the specialty and
who demonstrate a greater depth of experience and expertise in occupational medicine.
Doctors without these qualifications who rely solely on experience gained in the workplace
may not meet the requirements for competence that are demanded by health and safety
legislation. Therefore, it is recommended that the Diploma in Occupational Medicine be
used as the minimum standard for the construction industry.
However, individuals should work within the limits of their competence and be cognisant of
the need to access specialist occupational physician advice as needed. The level of
occupational health expertise will need to be commensurate with the level of health risk
identified for the project e.g. for a complex construction project such as the building of a
nuclear power station for example. it would be usual for the Occupational Health Provision
to be led by a Consultant Occupational Health Physician. The Faculty of Occupational
Medicine (www.facoccmed.ac.uk) can confirm the qualifications and specialist status of a
member. The Employment Medical Advisory Service of the Health and Safety Executive
(HSE) can also advise on both Occupational Health needs and services available locally.
Revalidation is the mechanism whereby doctors will demonstrate, at regular intervals, that
they remain up to date and fit to practice. In the near future, doctors who wish to practice
medicine in the UK will need to hold a licence to practice. To retain this licence, Doctors
will need to revalidate, normally every five years.

Occupational Health Nurses

Nurses carrying out occupational health surveillance should hold current registration with
the Nursing and Midwifery Council (NMC), as a minimum. They may also hold an
occupational health qualification at Certificate, Diploma or Degree level. If they do not
have an occupational health qualification then they should be working under the
supervision of an appropriately qualified clinician (Doctor or Nurse).
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Nurses will need to renew their registration every year with the NMC. For a Nurse led
Occupational Health Service, the lead Nurse should also be registered as a Specialist
Community Public Health Nurse (Occupational Health) with the NMC and have access to
specialist Occupational Physician advice as needed.
Occupational Health Technicians
The Occupational Health Technician is a developing role. With the expert supervision of
OH qualified Nurses and Doctors and the correct training, they may be able to carry out
aspects of health surveillance required within an OH programme. This in turn will free-up
the OH clinicians for other, more appropriate tasks. Currently there are no minimum
standards available to follow although there are academic organisations currently looking
to develop a training programme for technicians.
In addition to the fulfilment of the necessary legal requirements of employment of clinical
staff, it is recommended that the construction industry apply the following minimum levels
of competence:

Doctors: should hold the D.Occ.Med qualifications as minimum

Nurses: should be registered as a specialist nurse practitioner in public health

(Occupational Health)

Occupational Health Technicians: should be trained in the specific elements of the

service they deliver and must be clinically supervised.

Some aspects of health surveillance also require additional competences to be

demonstrated e.g.

Hand, arm vibration: a Faculty of Occupational Medicine approved training course

in HAVS or an equivalent level of competency

Noise induced hearing loss: a British Society for Audiology approved course for
industrial audiometricians or an equivalent level of competency.

Respiratory: Association for Respiratory Technology and Physiology (ARTP)

diploma or an equivalent level of competency.

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4.

SUITABILITY OF THE INDIVIDUAL FOR WORK

The aim of a pre-placement assessment is to ensure that people are placed in suitable
work and that any reasonable adjustments on the grounds of disability are able to be
made. For certain specific activities, there are legal duties to carry out pre-placement
assessments of an individuals fitness for work for example, under the Asbestos at Work
Regulations, the Control of Lead at Work Regulations (CLAW) and The Work in
Compressed Air Regulations). However, prudent employers should ensure that preplacement assessments are undertaken for all safety critical workers.
Baseline health surveillance assessments are also recommended (subject to a suitable
risk assessment) for individuals exposed to a number of hazards including handtransmitted vibration, noise, and silica. For low risk workers the provision of a health
questionnaire is considered suitable and sufficient. For medium and high risk (Safety
Critical Workers) a completed health questionnaire will be required in addition to an
assessment (medical check).
It should be noted that the use of medical selection to narrow the choice of job applicants
is wasteful of clinical resources. More importantly, it may lead to discrimination on the
grounds of disability, which may be difficult for an employer to defend legally. Therefore
pre-placement health screening is preferred after conditional offer (subject to occupational
health assessment) and acceptance of the job.
5.

PRE-PLACEMENT HEALTH QUESTIONNAIRES

Assessments are often conducted using self-administered questionnaires which are then
processed by either the human resources departments or occupational health staff.
However, there are a number of ethical and legal issues, which arise over the handling of
such questionnaires, which need to be considered.

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Applicants should not be expected to reveal clinical details to non-clinical staff (who are
not bound by medical confidentiality) as non-clinical staff are not qualified to interpret
medical data and should not do so. Only when questionnaires are returned directly to
qualified medical or nursing staff can there be any assurance that clinical details will be
handled in medical confidence. As information on the health of an individual is sensitive
personal data, its processing, which includes obtaining it, is subject to strict controls under
the Data Protection Act.
Health questionnaires should be reviewed by a competent person, such as a qualified
occupational health professional, to allow appropriate decisions on the management of
fitness for work issues and compliance with the Disability Discrimination Act to be made.
All the employer needs to know is whether the applicant is fit for the intended work and
any suggested adjustments that may be required. This can be a very difficult area, as the
individuals permission must be obtained before personal details are discussed with a
Manager, for example; even if the personal details could have implications for safety at
work.
6.

A HEALTH SCREENING PROGRAMME

Elements from a typical programme are in the following section.

7.

MEDICAL PROTOCOL

The employee will be asked to complete a general health questionnaire; perhaps with the
assistance of a nurse. The questionnaire will also contain questions about the individuals
health history and any health problems which relate to the work that they do to ascertain
whether or not their health is being affected by their work, and vice versa. Much of the
information about the employee is obtained in this way.

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Depending on the extent of the protocol the nurse will also ask the employee to undergo a
number of assessments to provide detailed information on the following:
1.

Height, weight and Body Mass Index (BMI): Height and weight will be taken and
the Nurse will provide the employee with the BMI. The BMI is a useful and quick
method for measuring whether the employee is underweight, overweight or obese.

2.

Blood pressure: The Nurse will take the employees blood pressure.

3.

Urine analysis: The employee will be asked to provide a sample of urine, which will
be dip-stick, tested to see if there is any protein, blood or sugar in their urine (these
test for kidney disease and diabetes).

4.

Review of noise exposure, past and present hearing problems and hearing test
(Audiogram). The test is conducted in a sound proof hearing booth and will last
approximately 15/20 minutes.

5.

Vision questionnaire and vision screen: The vision screen consists of looking
into a machine to recognise shapes/letters/colours and a colour vision test, which
consists of looking at a book and distinguishing the numbers from the patterns. This
is very important for trades such as electricians where colour blindness could make
the identification of coloured wires a problem.

6. Respiratory questionnaire and lung function test: The lung function test is undertaken
using a Vitalograph machine. All employees will be required to blow into this
machine these results show how healthy their lungs are.
7. Skin review: Employees will be required to complete a questionnaire about skin
problems. The Nurse will also look at the employees skin to check for rashes etc.
8. Musculo-skeletal review, particularly for upper limb, spine and vibration related (i.e.
white finger) disorders. This is undertaken via a questionnaire with the assistance of
a Nurse.
The length of time a full health assessment should take is approx 45 minutes to 1hour

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8.

PROCEDURE AND STANDARDS

9.

HEIGHT, WEIGHT AND BODY MASS INDEX (BMI)

HEIGHT
Equipment:

Standard metric/imperial measure

Procedure:

Individual removes shoes. The measure should be set up so

as to accurately read the height. The horizontal indicator must
rest level on the crown of the skull. Measure the height on the
scale. Record centimetres/inches.

WEIGHT
Equipment:

Scales (which have been checked for accuracy and the

calibration recorded)

Procedure:

Individual removes heavy items of clothing/personal belongings

(e.g. shoes, keys). Stands on scales. Weight is read from
scales and recorded in kgs/lbs.

BODY MASS INDEX (BMI)

Equipment:

Calculator

Procedure:

Calculate at time of assessment:

BMI

Weight (Kg)

Height (m) Compare with standards

The BMI is not necessarily an accurate assessment of correct proportion of fat to
muscle v height, particularly in the obese, or body builders. This should be taken into
account when assessing fitness.

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10.

VISION INTRODUCTORY NOTES

Class II = Large (previously called heavy) Goods Vehicle (refer to DVLA Standard
Guidelines)
Class I = Ordinary cars, small vans (<3.5 tonnes)
NB Separate category: 3.5 to 7.5 tonne Class II standard should apply

EQUIPMENT REQUIRED
Keystone Vision Screener and Record Sheets
Snellen chart 3m
Ishihara Colour Plates (24) and Record Sheets
Basic Procedure Visual Acuity
Test distant and near acuity, stereopsis and phoria colour vision, visual fields, night vision,
intermediate vision as appropriate (the latter particularly in the case of VDU users). Test
with normal correction (i.e. spectacles or contact lenses) in place.
NB Class II (LGV) drivers must have vision tested both corrected and uncorrected.
1.

If visual acuity for distance is worse than 6/9, 6/12 standard (corrected or
uncorrected), check with the Snellen Chart. A pass using the Snellen
chart will be allowed for all purposes.

PROCEDURE FOR TESTING VISUAL ACUITY

EQUIPMENT REQUIRED
Keystone vision screener VS11 Model 1136 A and results sheets Snellen chart (3 meter /
6 meter as appropriate)

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PROCEDURE
Check the VS11 is in proper working and that the lenses are clean and dust-free (clean
using soap and water dampened cloth when necessary).
The test should be performed in a quiet well lit environment. If more than one person is to
be tested they should be admitted to the test area one at a time.
Both examiner and subject should be seated comfortably throughout the test.
Using results sheet, complete employee details ensuring he/she has corrective lenses
where required.
Position subject so that they are able to sit with their back and head erect and shoulders
level. His/her head should be resting comfortably against the instruments headrest and
instructed to look through the top half of the lens to being the test.
Do not allow the subject to pull away from the instrument between individual tests.
Caution him/her against tilting the head to the side at any time.
The test should now commence following the manufacturers instructions. Corrective
lenses should be worn at the appropriate point during testing (i.e. glasses for distance only
for FAR and glasses for reading / VDU work for NEAR)

If the subject wears bifocals, examiner must ensure that he/she is looking through the
appropriate lens segment for each of the two test distances. Where corrective lenses are
used a note must be made on the results sheets.
On completion of distance/far vision test the subject should be instructed to adjust their
position until they are looking through the bottom half of the lens to complete the test.
On completion of the test, the examiner should interpret the results using the information
contained in the manufacturers instructions and follow the guidelines for pass / fail /
referral (see Vision Standards).
Those subjects failing to meet the standards for distance vision should be tested
using a Snellen chart (see separate instructions).
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PROCEDURE FOR TESTING VISION USING A SNELLEN CHART

EQUIPMENT REQUIRED
Snellen chart (6 metre / 3 metre)
Card suitable for eye occlusion
PROCEDURE
The test should be performed in an area with adequate lighting and the examiner should
ensure that the subject is the correct distance from the type of Snellen chart being used
(i.e., 6 metres or 3 metres).
The subject should now be asked to being reading the letters on the chart starting from the
top line and continue until he / she can no longer see the letters clearly.
The examiner should then record the last line on which the subject read all the letters
correctly on the keystone results chart already in use.
The examiner should now proceed to test the other eye in the same way and record the
results.
All subjects should be referred to the optician if they still fail to meet the standards.

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STANDARDS

Distant Acuity

Normally the 6/9 or 6/12

rule applies (unless advised
Drivers Class II, Mobile Plant, otherwise)
Forklift Truck
Lazy eye PASS if normal
visual fields
For true monocular vision
and other defects of visual
field, etc, refer to OHP for
advice
Drivers - Class I
Class I drivers should NOT
be restricted unless there
are serious concerns
regarding visual fields.

Fail:
Refer to Optician
Inform Manager that they
should not drive until vision
has been checked and
management are satisfied that
they are wearing a correction if
it is necessary
OHP will advise Company of
outcome.

Near Acuity

No Standard, but ensure

employee can read
instructions/equipment,
including keyboards, dials,
Leds, screens, etc.,
accurately.

If unacceptable, refer to
Optician. Do not restrict.
(Only restrict if serious
concerns re safety [of
employee, others or
equipment])

Intermediate Vision

No specific Standard

If unacceptable, refer to
Optician.
Do not restrict. Advise
employee to enquire about
Company DSE Policy.

Colour Vision

Normal colour vision is

required in certain
occupations e.g.
Electricians

For all non-railway employees,

check any suspected defect
with Ishihara.

NB: DO NOT INDICIATE A

RESTRICTION UNLESS
THE EXACT
RESTRICTION IS
SPECIFIED

Discuss with OHP before

taking further action

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Visual Fields

Good visual fields are

desirable, particularly in
Drivers, Plant Operators

If defective discuss with

Occupational Health Physician

Fusion

May be abnormal
(unacceptable) particularly
if phoria is also abnormal

If failed fusion alone, no further

action, but encourage to see
Optician at usual interval. If
fails, and phoria/steropsis
abnormal, refer to Optician.
Discuss need for restriction
with Occupational health
Physician

Fail Phoria

If acuity//fields normal

Refer to Optician
Do not restrict

If acuity and/or fields

fail/abnormal

Refer to Optician.
Restrict according to standard

If fails stereopsis and acuity

Refer to Optician.
May require restriction if acuity
failed (see standard)
Particularly

If fails stereopsis but not

acuity

Drivers of Plant etc.

Advise to see Optician at usual
interval
Do not restrict

Fail Stereopsis
(usually associated with
abnormality of visual acuity)

Employees should be encouraged to attend the Optician on the day of their assessment
and re-assessed on that day for a review of their (corrected) vision.
Ishihara Colour Vision Test
Pre-employment A deficiency in colour vision defect may have implications for certain
occupations (e.g. Electricians, Signallers). If a defect is identified, the result should be
discussed with the OHP who will advise on fitness.

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APPENDIX I
COLOUR VISION
TESTING PROTOCOL USING ISHIHARA
16 CHOSEN PLATES (See Guidance overleaf)
1 PRACTICLE PLATE

a.

Test in normal daylight or colour corrected day lamp.

b.

If the tested person requires correction he/she should be tested with their
Glasses/lenses.
Only clear glasses/lenses are appropriate for testing

c.

Place the book at arms length.

d.

The examiner should turn the pages

e.

Allow approximately 2 seconds per page

f.

Always start from plate 1 (you do not need to follow the numerical order
afterwards) and stop at plate no. 17.

g.

Record the answers on response sheet as you go along

h.

Check the answers given against the table enclosed

i.

Circle misreading or errors (misreading should be circled in black, errors in

red).

j.

Interpret the result and record it on notes.

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ISHIHARA TESTING

Plate

Normal
Person

Person with
Person with Red-Green Deficiencies

Total Colour
Blindness

12

12

12

29

70

15

17

74

21

45

10

11

12

16

13

73

14

15

45

Red

Green

Strong

Mild

Strong

Mild

16

26

(2) 6

2 (6)

17

42

(4) 2

4 (2)

The mark X shows that the plate cannot be read. Blank spaces denote that the reading is
indefinite. The numerals in parenthesis show that they can be read but they are
comparatively unclear.
Name:

Date:

Result:

Please Tick Box

Normal
Strong Red/Green Deficit
Mild Red/Green Deficit
Total Colour Blindness
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11.

HEARING
EQUIPMENT REQUIRED
Audiometer AMPLIVOX SERIES II / III (CA850)
Compatible keyboard and lead
Sound-proof hearing booth (The department of health recommend a minimum size of
1.2m by 1m and a height of 2m a comfortable seat and a window. Suitable booths
are available from several sources including INDUSTRIAL ACCOUSTICS COMPANY
LTD, ENGLAND.
It is not always possible to carry out hearing tests on site using a booth. Therefore,
as specified in ISO6189, a quiet environment is required and a background noise
reading should be taken using a simple sound level meter. Ideally the subject should
be sitting and have ambient noise levels continuously below 30 dB(A), although this
is rarely achieved without a sound booth.
If a booth is not available and background noise is of a reasonable level, audiocups
of MX41/AR cushions, which exclude more noise then the standard TDH39
headphone, should be used.
NB: Once headphones are calibrated to the audiometer, they cannot be changed
without re-calibration.
If the subject is having his/her audiogram for pre-employment screening to highlight
any pre-existing condition, it is recommended that a sound booth be used. Whilst
repeat audiometric tests without the use of a booth can be carried out, all the
employees previous and present test results should be scrutinised for abnormalities
and referred to a specialist for further investigations.
Appropriate printer paper (printers are supplied with Amplivox ll x lll)
Paperwork for recording history and results (example provided with this procedure
document).
Auroscope and disposable ear pieces
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PROCEDURE FOR AUDIOMETRIC TESTING

Ensure all equipment is working
Testing should take place in a quiet location away from loud / sudden noise
Where more than one subject is to be tested, they should be brought into the testing
area one at a time
Ideally the subject should not be tested immediately after exposure to loud noise
A full audiological history should be taken and documented (recurrent ear disease,
tinnitus, perforated ear drum, previous diagnosis of noise induced hearing loss)
The subjects ears should now be examined and findings documented
(wax/abnormalities)
The examiner should begin by giving the subject an explanation of the test
procedure.

Proceed to commence test following manufactures instructions which are supplied with
the equipment (copies attached for your information)
NOTE- the BECKESEY test is usually used but the computerised method should be used:At the point where the examiner has entered the subjects details, the subject should be
asked to enter the booth, sit down and make themselves comfortable.
The examiner should now give the subject CLEAR, SIMPLE and CONSISTENT
instructions.
Continue to run the test following manufactures instructions.
When the test is complete, invite the subject to leave the hearing booth and print out the
results.
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Calculate the low and high frequency results (add together the results of (0.5, 1 & 2
kHz) for low frequencies and (3 4 & % kHz) for high frequencies).

Categorise using health and Safety Executive (HSE) guidelines.

Advise subject of the results and refer to the standards provided with this procedure
document in order to assess the effects of these results on their competency to carry out
their jobs safely.
Advise management when necessary.
Refer to physician/GP for clinical opinion if warranted.
Calibration checks should be performed annually by a qualified technician.

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Highway Workers
Lone working in traffic

Low Frequency
Follow standard for PTS
(with exception to
individuals wearing good
quality hearing aids)

Fail:
If possible due to wax,
advise removal at GP
surgery and retreat
If no wax, advise fail and
inform employer/employee
and record in notes
Advise employee to
discuss result with own
GP as appropriate

Drivers Class I
Drivers Class II
Mobile Plant
Fork Lift Drivers

High Frequency
Assess ability to hear
warnings, (spoken,
electronic etc). A whisper
test may be helpful, but
take account of beneficial
effects of hearing aids
where they are allowed.

Heights
Confined Spaces

With the exception of Rail

workers, employees will be
allowed to continue working
normally if they use an
effective hearing aid.
(Please not, Rail workers
cannot work unaccompanied even with
hearing aids unless they
pass the hearing test
standard.

Noisy Areas
Restriction for Highway
Workers/Lone Workers:

Accompanying on/near
highways at all times.
Not to take responsibility
for safety on highway

Non-Railway Workers
Low/High Frequency Loss

No Standard, but HSE

Category should be
referred to and the
employee counselled with
the resulting categories.

Significant high or low

frequency hearing loss i.e.
with a significant effect on
awareness/concentration
and / or ability to
communicate may need to
be brought to the attention
of employer. All such cases
should be documented and
discussed with the OHP.

Page 25 of 63

12.

LUNG FUNCTION

EQUIPMENT REQUIRED

Vitalograph Alpha II Portable Office Spirometer with integral screen and thermal printer
Precision syringe for checking accuracy (available from Vitalograph)
Disposable cardboard mouthpieces
Accurate free-standing measure to measure height of subject in centimetres
Appropriate container for disposal of used mouthpieces
Mains electricity supply
Room thermometer
PROCEDURE
Plug vitalograph in and switch the unit on. Check that there is an adequate amount of
printer paper in place.
Perform accuracy check and update calibration as required.
Using the keyboard and following the written instructions on the vitalograph screen.
Enter:The ambient temperature of the room (CHECK BEFORE EACH TEST), and the correct
date. The menu will now appear select NEW SUBJECT and proceed to enter the:Age
Height
Sex
Ethnic origin of current subject
The printer will now start automatically which confirms the subject has been entered as the
current subject
From the menu now select VC TEST and insert unused mouthpiece into flow head.

Page 26 of 63

The subject should now be instructed as follows:1) Stand or sit upright in front of the unit
2) Take hold of flow head unit, keeping it in a vertical position and away from the mouth.
(Ensure the device is not jerked whilst handing it to the subject)
3) Inhale as deeply as possible and then insert the mouthpiece into your mouth, clamping
it between your teeth
4) Close your lips around the mouthpiece
5) Exhale normally for as long as possible

Now press ENTER to return to main menu

From the menu now select FVC TEST and repeat instructions 1 4 above
The instructions for step 5 should now be given as follows:Exhale as quickly as possible and try to keep exhaling for at least 6 seconds
Remove used disposable mouthpiece
Now press the ENTER button to return to main menu
From main menu now select PRINT
The results of the VC test and the BEST FVC test will now be printed along with the
predicted results for this subject
From the menu now select NEW PATIENT. The screen will now show ALL RESULTS
WILL BE CLEARED (Y) OR (NO) select (Y). The Vitalograph is now ready fro the next
subject
The results should now be interpreted using the guidelines provided (see Appendix 1). For
further information on operating, cleaning, calibrating and maintaining the Vitalograph Alph
II, please refer to the separate internal guidance and the manufacturers instruction manual
which is supplied with the unit.

Page 27 of 63

NB: If the employee becomes distressed or breathless then the test should be
suspended and this should be documented. The test may need to be repeated at a
later date. The nurse should follow the guidelines laid out in the treatment of
anaphylaxis, ensuring the employees safety and call the emergency number
provided at the site, if required.
GUIDELINES FOR INTERPRETING RESULTS OF LUNG FUNCTION TESTS
The results of the following measurements are recorded automatically on completion of
lung function tests following the procedure provided:
VC

(vital capacity)

FEV1

(forced respiratory volume in 1 second)

FVC

(forced vital capacity)

PEFR

(peak expiratory flow rate)

FEV1%

(FEV1% to FVC ratio)

FEF (25-75)

(forced expiratory flow rate)

Both FEV1, FVC and PEFR should fall within the expected range for age, gender and
height. The ACTUAL result should be checked against the PREDICTED.
The FEV1% should be greater than 75%. An FEV1% of less than 75% indicates possible
obstruction (narrowing of the airways i.e. asthma, bronchitis) which may warrant referral to
the subjects own doctor for further assessment. This would not be necessary in the
absence of a clinical history and/or symptoms.
An FVC% (predicted/actual x 100) of less than 80% may indicate significant disease of the
lung tissue (e.g. fibrosis) and may warrant referral to the subjects own doctor in the
presence of clinical history.
The FEF (22-75) should be greater than 55% or obstruction particularly due to small
airways disease is indicated and referral to the subjects own doctor is required. A result
of over 55% but less than 75% may indicate a defect but due to the normal variability of
this parameter it should not be used in isolation.
Page 28 of 63

Changes of 5% or more between current and previous results (where available) should be
deemed as significant and they should be taken into account in future health assessments.

STANDARD

WITH

WITHOUT

TASK

RESULT

All occupations, in

FEV1 <80%

Restrict from

Advise employee

particular those with

FVC

exertional work

review history

a significant manual

(either or both)

until

respiratory/smoking

Reviewed by

history.

physician

Counsel and refer

<80%

handling component.
And/or FEV1%

SYMPTOMS

SYMPTOMS

PERFORMING AN ACCURACY CHECK ON VITALOGRAPH ALPHA II

Accuracy should be checked at the start of each session and at frequent intervals if
several tests are being performed.
A 1 litre precision syringe is required (for details see procedure).
The flow head and syringe must be at the same temperature. If the flow head has been
recently used, then the temperature must be lowered to the ambient by repeated blowing
air through it, using the syringe.
Following the instructions on the screen select CALIBRATION CHECK.
Using the precision syringe blow air through the flow head press ENT key.
After ambient temperature if necessary.
Pump air through the flow head at a smooth continuous rate. Pres ENT key.
Enter calibration volume (e.g. 1L, 2L, 3L depending on how much air is pumped through
the flow head).
Page 29 of 63

IF THE ERROR MESSAGE IS LESS THAN 3% THEN THE DEVICE IS ACCURATE.

PRESS (N) AS THERE IS NO NEED TO UPDATE THE CALIBRATION.
IF THE ERROR MESSAGE IS GREATER THAN 3% RECHECK THE ACCURACY BY
PRESSING (N) TO UPDATE CALIBRATION FOLLOWED BY (Y) TO RETEST.
IF THE ERROR MESSAGE IS STILL GREATER THAN 3% PRESS (Y) TO UPDATE
CALIBRATION (WHEN CALIBRATION HAS BEEN ADJUSTED ACCURACY SHOULD
AGAIN BE CHECKED).
A calibration CHECK will now be printed if no update was required.
A calibration REPORT if an update was required.
CLEANING VITALOGRAPH ALPHA II
All parts of the unit should be cleaned regularly.
The flow head assembly (i.e. the CONE and the ELEMENT) should be cleaned and
disinfected on a weekly basis.
The FLOW CONDITIONING MESHES should be replaced regularly (at least monthly or
every 100 subjects i.e. 500 blows) in the event of damage or if visibly contaminated.
The FLOWHEAD COMPLETE and FLOWHEAD CONNECTION TUBE should be replaced
annually.

Page 30 of 63

13.

BLOOD PRESSURE

EQUIPMENT

Standard sphygmomanometer / Stethoscope / Cuff preferably adjustable, otherwise

standard and large.
PROCEDURE

The blood pressure should be measured using a standard sphygmomanometer and cuff.
The cuff should be at least half as wide as half the arms circumference. The new
generation of automatically adjustable cuffs should be used in preference to the older
wrap round type.
Readings should be taken as follows:
1)

Systolic when the initial softer sounds become harsher and more tapping) in
quality

2)

Diastolic when the sounds cease altogether

Blood pressure will vary accordingly to the state of the patient. Employees will naturally be
anxious and this may influence the readings. Normal blood pressure should be no more
than 120 systolic and/or 80 diastolic. However, the systolic pressure increases with
advancing age.
Confirmed Hypertension
If the blood pressure exceeds 160 systolic and/or 100 diastolic consistently over a 6 month
period (British Hypertension Society), and these results are based on at least 3 readings,
each a week apart, the employee would be regarded as having an abnormal blood
pressure. It is obviously not possible to record employees blood pressure at weekly
intervals, nor is moderately raised blood pressure necessarily a bar to safety, unless it is
likely to impair health or there is evidence of and/or pathology (e.g. myocardial infarction,
stroke, renal impairment, visual impairment).
Page 31 of 63

Borderline Hypertension:
If the systolic exceeds 140 and/or the diastolic exceeds 90 respectively (but not both).
Probable Hypertension:
If the systolic is greater than 140 and the diastolic is great than 90.
Note that the systolic pressure increases with advancing age.
STANDARD
Drivers (Class II, Mobile
Plant including Fork Lift
Truck)
(DVLA) bans driving of
Class II vehicles if BP
exceeds 180/100 until
controlled without side
effects from medication)

Safety Critical Workers

Crane Operatives

Class I Drivers

General operatives
Consider if working at
height, alone or in
confined spaces

Borderline (i.e. systolic

> 140 or diastolic > 90)

If systolic >140 and >90 but

<180/100

Repeat if possible.
Advise employee and
refer to GP
___________________
Repeat later in the day if
possible. If still raised,
refer to GP

Systolic >180 and/or diastolic

>100

Inform OHA/OHP who will

advise re restriction if
necessary

A restriction may be
necessary if BP exceeds
systolic of 180 and/or diastolic
of 100, particularly if there are
symptoms associated with
hypertension. In on
medication, ascertain if there
are any side effects which
may affect safety e.g.
dizziness, visual disturbance.
If systolic >140 and/or
diastolic >90 but <180/100 no
restriction will be applied
unless there is concern re
employees welfare and/or
safety.

Inform OHA/OHP who will

advise re restriction if
necessary.

Guidelines for Class I Drivers

Guidelines for Glass I

Drivers

Advise employee. Refer

to GP and discuss with
OHA/OHP if concerned re
employees welfare
(and/or evidence of other
illness)

Page 32 of 63

14.

URINALYSIS

EQUIPMENT REQUIRED
Specimen Pots, Labstix, Accutrend / Glucotrend Machines
PROCEDURE
Test urine (preferably but not essentially a fresh specimen) with Labstix. Dispose of waste
hygienically.
Standard

All Occupations

Drivers, Class I and

Class 2

Whether know diabetic or not

Refer to GP using appropriate
form. Obtain consent as
appropriate.
Known diabetics, poorly
controlled:restrict if Class 2 driver, driver
of mobile plant, or safety
critical.
Other drivers need to see their
GP but will not require a
restriction unless they are on
medication which may require
adjustment and may cause
hypoglycaemia/side effects.
Potential new diabetics:Normally restrict as for Class 2
drivers or safety critical until
investigated and fit, with or
without medication

Glycosuria (trace, 1, 2 or 3+)

repeat on fresh specimen.
If positive, try to obtain blood
sugar on finger prick sample
(preferably also offer test on
venepuncture)
If blood sugar high (>9) advise,
refer to GP and inform OHP.
If blood sugar normal
(3-9) advise, refer to GP.

May require restriction until fit.

Consult OHA/OHP

PLEASE REFER TO DVLA

GUIDELINES FOR DETAIL
REGARDING NEW/EXISTING
DRIVERS, CLASS 1
AND 2
Railway Workers
(Trackman, O/H
Linesman, etc)

Will usually be temporarily restricted pending further

investigations. Inform OHP and discuss

Proteinuria,
Haematuria,
Other

Retest on fresh sample. Inform employee and refer to GP. Do

not restrict unless OHA/OHP advises.
Page 33 of 63

15.

VENEPUNCTURE
Equipment:

Procedures:

Monovette/Vacutainer

Needle stick injury

Needles

Disposal of clinical waste

Tourniquet
Plasters
Sharps Box
Gloves
Cotton wool buds

PROCEDURE

1)

Seat the patient or lie them down if they are needle phobic or faint easily.

2)

Explain procedure. Check for any special risks of bleeding, clotting deficiency,
Warfarin therapy do not proceed but D/W OHP.

3)

There is no need to clean or sterilise the skin unless it is obviously dirty.

4)

Apply tourniquet, select a vein, insert needle at 30 and withdraw blood.

5)

Place a gauze/cotton wool swab over the puncture site as the needle is removed.
Get the patient to press firmly on the swab with the arm straight for two minutes.

6)

Discard (do not re-sheath) the needle immediately to a sharps bin, which should be
located within comfortable reach of you (but not that of children).

Page 34 of 63

RISKS ASSOCIATED WITH VENEPUNCTURE

1. CONTAMINATION
There is no risk of contamination of the sample as health care workers always use the
vacutainer system to obtain the sample. The collection of the blood sample is carried
out in a clean environment using single use gloves. This method prevents cross
contamination.
2. NEEDLE PHOBIA
The employee is asked if they have a needle phobia prior to carrying out the
procedure. If they have a needle phobia, they are invited to lie flat on the floor with
their legs elevated on a chair or if there is access to a first aid room, then they should
be advised to lie on the couch during the procedure. Following the procedure, they are
monitored for 10 minutes to ensure they have recovered enough to resume their usual
activities.
Policy and Procedure in the event of needle stick injury
1.

Needle stick injuries occur most frequently when needles are re-sheathed.
Therefore needles should not at any time be re-sheathed but should be disposed of
directly into the appropriate container for use.

2.

In the event of a needle stick injury, the wound should be encouraged to bleed as
profusely as possible and run under clean, running water for at least five minutes.
There is a risk of transmission of Hepatitis B and/or HIV, but this clearly depends on
the status of (a) the donor and (b) the recipient.

Page 35 of 63

The following steps should always be followed in the event of a needle stick injury:
1.

The wound should be attended to as above and a clean dressing applied

eventually.

2.

The following details should be obtained from the donor:

Name
Address
Date of Birth
Medical History past history of infection with Hepatitis B and/or HIV

If possible, a sample of blood from the donor should be obtained with their consent to be
tested for Hepatitis B and/or HIV.
3.

If the donor admits to past infection from Hepatitis B and the recipient has not been
immunised against Hepatitis B, then a blood sample should be obtained from the
Recipient and arrangements should be made for it to be tested for Hepatitis B
status.

4.

If the donor admits to a past history of Hepatitis B and the recipient has been
successfully immunised against Hepatitis B within the last 5 years, no further action
need be taken but the needle stick injury should be entered in the accident book
and a note made in the doctors file for future reference.

5.

If the donor admits to being HIV positive and the recipient is HIV positive, no
further action need be taken.

6.

If the donor admits to being HIV positive and the recipient is not HIV positive, the
recipient should seek advice from an appropriate medical authority as to whether or
not HIV testing should be carried out. It should be borne in mind that it can take
several weeks for the recipient to convert to HIV positive.

Page 36 of 63

Please be assured by the fact that infection through needle stick injury amongst health
workers for both Hepatitis B and HIV is relatively rare. The incidence is still as far as we
are aware around 0.1% transmission amongst health workers for HIV alone.
If the needle stick injury occurs before a vein has been punctured, then there is less
likelihood of transfer of significant blood products. If the needle stick injury involves
contamination with blood which has been within the needle for more than four to six hours,
then whilst the risk of Hepatitis B infection presents, the risk of HIV infection will be very
low as the virus does not survive readily outside the body tissue.
General points:1.

All needle stick injuries should be reported to their Manager and an opportunity is
afforded to discuss the matter with an Occupational Physician. If they are more
distant then they can make their own arrangements, either via the local Accident
and Emergency Department or their own General Practitioner.

SAFE USE AND DISPOSAL OF SHARPS

A sharp is any item that is capable of penetrating the skin, i.e. needles, glass slides,
ampoules, Stitch cutters.
ALL STAFF MUST DISPOSE OF SHARPS CORRECTLY:

The person using the sharp is responsible for the safe disposal of it in a sharps
container. The sharps container should be situated in an area where the sharps are to
be used. NEVER carry sharps in hands or pockets.

Used needles must NEVER be RE-SHEATHED, CUT or BENT.

The syringe should NEVER be DISCONNECTED from the needle; it should be

disposed of as a single unit. Wherever possible the operator should wear disposable
gloves if he or she has any cuts, abrasions or broken skin on the hands when a blood
sample is being taken.

Page 37 of 63

Sharps containers should comply with the British Standards Institutes regulations (DoH
1989) and be marked accordingly. They should be coloured yellow and white/blue and
clearly marked sharps. The date and the name of the assemble should be clearly
marked at the time of assembly. No other container should be used.

Sharps containers should be kept out of reach of children and others.

The container should not be more than two thirds full or above the fill line.

Appropriate sized sharps containers should be used. Large objects should not be
forced into small containers.

The date and name of the person responsible for sealing the sharps container should
be clearly written on the side of the container, enabling the waste to be traced back to
its point of origin.

THE DISPOSAL OF CLINICAL WASTE

The Environment Protection Act (1990) requires that:1.

Waste is stored correctly until collected.

2.

A written description of the waste is provided

3.

The waste is transferred to a registered carrier

SEGREGATION OF CLINICAL WASTE

Clinical items, i.e. dressings and other soft waste contaminated with blood or body
fluids must be placed in yellow bags. These bags should not be more than full.
Blades and sharp items must be disposed of in a sharps container which meets the
British Standard BS7320.

Page 38 of 63

The person responsible for sealing the clinical waste bag should make sure that the
bag is no more than two thirds full. The bag should be sealed with a tag and the
bag clearly labelled with the date and name of the person sealing the bag.

GENERAL WASTE (NON-CLINICAL)

General waste, including paper should be placed in black bags and disposed of with other
household waste.

Page 39 of 63

16.
1.

MUSCULOSKELETAL ASSESSMENT
The purpose of the assessment is to ascertain whether or not the individual is
suffering from recognisable musculoskeletal problems and identify.
a)

Whether or not they are likely to be related to, or made worse by work,
and/or

b)

Whether or not they are likely to affect the individuals fitness for work.

2.

The clinical questionnaire should be completed with the employee.

3.

A general assessment of mobility and agility should be carried out by completion of

the supplementary questionnaire (attached). The individual should be asked to
complete the tasks listed on the questionnaire and a judgement made as to whether
or not they were able to complete the tasks satisfactorily.

4.

A decision should be made as to whether or not:

a)

There is a work-related problem

b)

Its implications for on going work in terms of fitness or likelihood of

exacerbation

c)

There is sufficient mobility and agility for the individual to be able to carry out
their given duties safely, effectively and without detriment to their welfare.

Page 40 of 63

Medical Standard
1.

The individual who is experiencing on-going i.e. musculoskeletal problems which they
feel is caused by work and/or affects their ability to work, then a more detailed
medical assessment should be carried out with an Occupational Physician and an
opinion be obtained as to:
a) Whether or not the individual is fit to continue working in their given capacity,
b) Whether any adjustments or restrictions are necessary,
c) Whether any further investigations are necessary in order to provide more
detailed advice regarding future management at work.

2.

In some cases an individual may be experiencing significant problems because of

Musculoskeletal problem which necessitate adjustment/restriction or even removal
from one or more tasks, in which case advice should be given to management so that
a risk assessment can be carried out and appropriate action taken.

3.

There will be a number of individuals who state that they have a work-related
musculoskeletal problem or indeed one which is not work-related but which has been
present for some time and is well controlled. In such cases, the individual may not be
experiencing any problems at work, but it may be appropriate for
management to be informed that they should review the risk assessments relating in
particular to manual handling activities to ensure that the individual does not
experience problems in future.

Page 41 of 63

17.
1.

SKIN ASSESSMENT
The purpose of this assessment is to ascertain whether or not an employee is
suffering from a skin problem that might be caused or made worse by work and/or
may affect their fitness for work

2.

The clinical questionnaire should be completed by the employee.

3.

An elementary inspection of skin should be carried out looking particularly at

exposed areas, i.e. those areas such as the hands/face, which may come into
contact with substances during the course of work activities. If there is evidence of a
skin problem particularly dermatitis, on the exposed areas then the employee should
be asked if there are similar problems affecting other parts of the body.

4.

Appropriate note should be taken and entered on to the questionnaire.

5.

In particular, the examiner should look for evidence of rashes which may indicate
Dermatitis and also any other skin conditions such as psoriasis, eczema, fungal or
bacterial infections that might become contaminated by substances at work and/or
making cleaning of the skin more difficult.

Medical Standard
1.

Any individual who is suspected of suffering from a work-related skin problem such
as Dermatitis should be referred for a full medical assessment and advice given to
the company regarding further protection from exposure to substances that may
have caused the dermatitis whilst further investigations are carried out. If there is a
likelihood of sensitization, then arrangements will have to be made for the individual
to undergo patch testing with a Dermatologist.

2.

If a work-related skin problem is suspected, the company should undertake a risk

assessment and take appropriate action.

Page 42 of 63

3.

If the individual is suspected of having a skin problem which is not necessarily workrelated but may impinge on their ability to work safely and effectively, account
should be taken of this and the company informed so that a risk assessment can be
carried out and appropriate protective measures can be instigated to protect the
employees skin from further harm.

4.

There may be circumstances in which the skin problem is so severe that the
individual needs to be restricted from certain work activities. Management should
be informed of this opinion and take appropriate action.

Page 43 of 63

18.

ASSESSMENT FOR HAND ARM VIBRATION SYNDROME (HAVS)

1.

Hand Arm Vibration syndrome (HAVS) comprises 3 main elements:a)

Vascular white finger (blanching)

b)

Sensorineural numbness and/or tingling

c)

Musculo-skeletal a variety of symptoms and signs including aching in the

fingers, hands, wrists or forearms, loss of grip/cramps and other sensations
in the upper limbs.

NB

Numbness and/or tingling may occur in association with white finger whilst
blanching is present.

2.

White Finger
White finger occurs in reaction to cold temperatures but not to vibration itself.
Numbness and tingling may occur during and after the use of a vibrating tool
therefore it is important to ascertain if this is the case and if so how long the
symptoms last after they stop using the tool. It is also important to ascertain
whether or not any numbness or tingling occurs at other times i.e. when tools are
not being used.

3.

Document as accurately and clearly as possible any sins and symptoms which may
indicate HAVS. The purpose of this screening is to act as an initial filter so that
potential cases can be more closely evaluated by means of the details HAVS
questionnaire and if required, subsequent assessment by an OHA/OHP. Based on
the responses in this further questionnaire, the physician will stage the condition
and recommend further action e.g.
~ confirm via OHA assessment
~ confirm via OHP assessment
~ refer for Standardised Testing

Page 44 of 63

APPENDIX II
Supplementary Clinical Guidelines

Clinical

Main Features

Circumstances

Vascular

Blanching (white finger)

Clear demarcation, variable
phalanges/digits affected.
White
Purple
Red
Blanching may cause numbness,
recovery may produce tingling.

White finger occurs in

response to cold i.e. low
temperatures not
exposure to vibration.

Sensorineural

Numbness (loss of normal

sensation) which may or may not
be associated with tingling (pins
and needles/parasthesiae). May
occur during use of vibrating tools
and persist for some time after.
Important to ascertain if symptoms
appear to be more persistent i.e.
occurring at other times,
particularly when relaxing e.g. at
night, on walking.

May occur whilst using

tools and persists for
variable periods after, but
may also occur in more
severe cases at other
times.

Various symptoms/signs most

commonly cramps/aches/pains in
fingers, wrists, forearms, Many
employees will have arthritic
changes as a result of manual
handling. These may be
aggravated by the use of Jack
Hammers etc. Other conditions
e.g. Carpal Tunnel Syndrome,
Dupytrens Contracture may be
associated but cause/effect with
vibration not demonstrated
scientifically.

Symptoms appear to be
most commonly related to
the prolonged use of Jack
Hammers with the
exception of Carpal Tunnel
Syndrome and Dupytrens
Contracture. Soft
tissue/musculo-skeletal
signs and symptoms are
exacerbated by exposure to
vibration rather than directly
caused by it.

Component

Musculoskeletal

NB Symptoms may be
associated with peripheral
nerve damage e.g.
ulnar/median nerve
problems.

Page 45 of 63

THE STOCKHOLM WORKSHOP SCALES

Vascular Component
Stage
0

Grade

Description
No attacks

1V

Mild

Occasional attacks affecting only the tips of one or

more fingers

2V

Moderate

Occasional attacks affecting distal and middle

(rarely also proximal) phalanges of one or more
fingers

3V

Severe

Frequent attacks affecting all phalanges of most

fingers

4V

Very Severe

As in Stage 3 with trophic changes in their fingers

Sensorineural Component
Stage
0SN

Description
Vibration exposed but no symptoms

1SN

Intermittent numbness with or without tingling

2SN

Intermittent or persistent numbness reduced sensory perception

3SN

Intermittent or persistent numbness reduced tactile discrimination and/or

manipulative dexterity.

Note:
The staging is made separately for each hand. The grade of disorder is indicated by stage
and number of affected fingers on both hands, e.g. stage/handling/number of digits. It is
customary to report the overall grade according to the most severe Stage documented:
E.g.

Result:
Right
Left

Vascular
3
2 (early)

Sensorineural
2 (late)
1

Overall Stage is 3
Page 46 of 63

19.

DRUG AND ALCOHOL

ESSENTIAL REQUIREMENTS
Urine Samples
Private facilities and space for completion of paperwork
Toilet cubicle allocated for the use of collection officer only
Site preparation checklists
Sign to alert others that tests are in progress e.g. MEDICAL IN PROGRESS
Sign to remind Donor not to flush the toilet e.g. DO NOT FLUSH
Means of colouring the water in the cistern e.g. Blu-Loos or similar
Tamper proof tape for sealing the cistern and/or taps
Adequate supplies of specimen collection kits (at least six for each Donor)
Collection Agencys Donor Guidelines
Chain of custody forms
Current medication questions
Collection Agencys Specimen Collection Procedures as a source of reference
Envelopes in which to place Donors possessions
Refusal to provide and Unable to provide sample forms
Labstix
PROCEDURE
On arrival at the site identify the toilet facilities allocated to you.
Ensure that the facilities are suitable in accordance with Collection Agencys collection
procedures.
Welcome the Donor and give the Donor an explanation of the test procedure.
Explain in particular the following:1) The importance of disclosure of all medication taken in the 10 days preceding date of
collection, including injections received in the previous 14 days, prescribed medicines
and proprietary medicines.
2) The significance of the second sample.
Page 47 of 63

Ensure that the donor has the appropriate photographic identification required as
documented in the CANDIDATE IDENTIFICATION FOR THE PURPOSES OF A DRUG
AND ALCOHOL TEST guidelines. Where are these? In all cases this should be done
before asking them to read the consent form.
Ensure that the Donor reads and fully understands the information on the consent form
and then ask them to sign if they are happy to do so (please ensure that the DO/DO NOT
is deleted as appropriate). If the Donor is unable to read the form, read it to them or ask
for a translator. Document your actions on the COC form and in the notes.
Commence the collection using Collection Agencys Collection Procedure Guidelines (NB
if routine analysis of the urine using a lab stick is required; this should be performed on
any urine remaining after you have transferred an adequate amount into the two
containers to avoid the risk of contamination).
Upon reaching step four on the guidelines, complete the INFORMATION REQUIRED BY
COMPANY section ensuring you use the correct code and the name of the company
requesting the test on the top line (refer to separate form).
Upon reaching step five on the guidelines complete THE DONOR DETAILS using the
appropriate photographic identification (Refer to candidate identification for the purposes
of a drug and alcohol test guidelines).
Upon reaching step six on the guidelines, invite the Donor to place his/her possessions
into an envelope, observed by the Donor, seal the envelope. Donor and collection officer
must then sign across the seal. Place the envelope in a lockable drawer and keep the key
with you at all times. Upon leaving the unit to obtain the sample lock the door. Reassure
the Donor that no one will have access in your absence. Upon reaching step twenty three
on the list, return the sealed envelope to the Donor ensuring the seal is not damaged.
When the collection is complete ask the Donor if he/she has any further questions.
The Donor may now leave.
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Ensure you have all the relevant completed paperwork

Send the sample to the testing laboratory in a padded envelope using address label
provided.
When a Donor is unable to refuses to provide a sample or refuses to sign the consent
to test, terminate the collection and complete the appropriate forms (i.e. unable or
refusal declaration). Ensure the Donor understands the implications as outlined on the
relevant forms.
NB: - For a Donor to be deemed unable to provide a sample he/she must have been
allowed to consume a maximum of 1 litre of water given in amounts of 250mls at 20
minute intervals. They should be allowed a maximum wait of 2hrs. Document the amount
of water given in the comments box on the Chain of Custody Form.
If you have any concerns with regards to the appearance of the sample, follow the
collection agencys guidelines and document your concerns both on the chain of custody
form and in the notes in the case of a full medical.
On completion of all collections, remove all signs and tape from toilet facilities and inform
your contact that they are now free for normal use.
NB: If several collections are to be carried out, the Collection Officer MUST recheck the facilities for signs of tampering prior to each collection.

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ORAL FLUID (MOUTH SWAB) SAMPLING

The advantage of mouth swaps over a urine sample is that it is more difficult to adulterate,
more hygienic and less intrusive for the donor.
Essential requirements
Private facilities and space for paper work
Adequate supplies of specimen collection kits (at least six per donor)
Collection Agency Donor Guidelines
Chain of Custody forms
Current Medication Questionnaire
Collection Agency specimen procedures, as a source of reference
Refusal to Provide Sample forms
Procedure
Welcome the donor then give the an explanation of the test procedure which should
include that the donor has the appropriate photographic evidence to corroborate he/she is
the correct donor
1. The importance of disclosure of all medication taken in the last ten days, including
injections received in the last fourteen days.
2. The significance of the second sample
3. Ensure the donor reads and fully understands the information on the consent form,
then ask them to sign the consent form, if they are happy to do so
4. Complete the information required by company section ensuring you use the correct
code and the name of the company requesting the test on the top line
If the first oral fluid specimen is positive and as it has been proven that oral fluids have a
much shorter shelf life than urine, a urine specimen may be taken as an alternative for a
chain of custody,
The urine collection protocol should then be followed.
When the collection is complete ask the donor if he / she has any questions
The Donor may then leave.

Page 50 of 63

SITE PREPARATION CHECKLIST FOR URINE COLLECTIONS FOR

LEGALLY DEFENSIBLE DRUG AND ALCOHOL TESTS

DATE
LOCATION
COMPANY
NAME OF
COLLECTION OFFICER
STEP REQUIRED
At the start of collection session (one
cubical only to be used)
Placing of Medical in Progress sign?

ADEQUATELY
PERFORMED
YES
NOT

RECHECKED
YES

NOT

Placing of Do not flush sign?

Blu Loo placed in cistern?
Cistern sealed with tamper evident tape?
Any ground floor windows are locked?
Potential hiding places are clear and all
cleaning products or potential contaminants
are removed?
Before each collection
Signs are still in place and visible?
Tamper evident tape is in place and not
damaged?
Any ground floor windows remain locked?
Potential hiding places remain clear and all
cleaning products or potential contaminants
are removed?
All taps that are within the cubicle are sealed
with tamper evident tape?
No third party present during the collection?

SPECIMEN COLLECTORS INSTRUCTION

UNABLE TO PROVIDE A SPECIMEN FOR DRUG AND ALCOHOL TESTING

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I .. (full name of donor)

Confirm that I was unable to provide a urine specimen, which was satisfactory for
the purposes of a drug and alcohol test, after 2 hours, having been provided with
250mls of drinking water every 20 minutes up to a maximum of 1,000 mls.

The company who have requested the test is .

I understand that the company will be informed that I was unable to provide a
suitable specimen and that I may be required to re-attend for a drug and alcohol
test in the future. I am aware that failure to do so will be treated in accordance with
the companys policies and may lead to rejection of a job offer/disciplinary action
against me. *

Signature of donor:
Date:
Time:

I, (full name of Collection Officer)

Certify that the above named individual was unable to provide a suitable urine
specimen as stated above. *

Signature of Collection Office:

Date:
Time:

* Delete as appropriate

Page 52 of 63

SPECIMEN COLLECTORS INSTRUCTION

UNABLE TO PROVIDE A SPECIMEN /REFUSAL TO GIVE CONSENT FOR
DRUG AND ALCOHOL TESTING

I .. (full name of donor)

Have been asked to provide a urine specimen for the purpose of a drug and alcohol
test.

The company who have requested the test is .

I understand that the company will be informed of my refusal and that this will be
treated in accordance with the companys policies. I also understand that my
refusal may lead to rejection of a job offer/disciplinary action against me. *

Signature of donor:
Date:
Time:

I, (full name of Collection Officer)

Certify that the above named individual has refused to provide a urine specimen for
the purpose of a drug and alcohol test/has failed to give their consent for the
specimen to be used for such a test. *

Signature of Collection Office:

Date:
Time:

* Delete as appropriate

Page 53 of 63

20.

CHOLESTEROL TESTING

Introduction
A raised level of cholesterol in blood is known as hypercholesterolemia. This is a known
risk factor for Coronary Heart Disease but is just one of several risk factors. Other known
non-modifiable factors increasing the risk are male gender, a family history, diabetes and
certain races. Lifestyle factors that are modifiable include cigarette smoking, high blood
pressure, alcohol consumption (excessive and very low), inactivity and obesity.
Coronary heart disease and stroke remain the most common cause of death in the UK.
One in 12 men dies from CHD before the age of 65. The combined effect of all risk factors
on risk is cumulative. It is very important to consider other risk factors for heart disease.
For example, even if cholesterol is only 4.5mmol/L if overweight, have high blood
pressure, smoke and take little exercise there remains a relatively high risk of heart
disease.
Health Surveillance
There are no requirements to undertake testing for raised cholesterol for non-safety critical
workers, but can be used as part of a general health / lifestyle programme, or for those in
safety critical / increased risk roles as part of the fitness for work assessment.
Frequency
3 yearly if used as part of the cardiovascular health re-assessment for Fitness for Work.
The National Institute for Health and Clinical Excellence (NICE) and Department of Health
cholesterol guidelines, which is the policy doctors follow, are:

total cholesterol: less than 5.0mmol/l

LDL cholesterol: less than 3.0mmol/l give description of anagram

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However, the Joint British Societies (a group of the main UK expert societies involved in
cardiovascular disease) recommend different cholesterol limits for people who have, or are
at risk of, coronary heart disease:

total cholesterol: less than 4.0mmol/l

LDL cholesterol: less than 2.0mmol/l

HDL cholesterol: more than 1.15mmol/l give description of anagram

triglycerides: less than 1.5 mmol/l

These guidelines match the more stringent recommendations used in Europe.

NICE is currently reviewing its national policy guidelines.
21.

HEALTH PROMOTION

Health surveillance provides a unique opportunity to promote not only work related health,
but also general health and well being. Employers are increasingly recognising the value
of including health promotion in their health surveillance programmes. Issues such as
smoking, weight loss, healthy eating and exercise, alcohol, mental, cardiovascular and
sexual health can be incorporated. Investigations such as blood tests (for cholesterol and
lipids, liver and kidney disease, diabetes, and prostate function) and electrocardiographs
can be undertaken with minimum discomfort and disruption.
Employees feel valued as a result, and appreciate the opportunity to discuss issues which
they might not otherwise have the time to raise with their GP; they are less likely to feel
that the health surveillance is just for the employers benefit, and more likely to participate
willingly in the programme.

Page 55 of 63

22.

MEDICAL PROTOCALS, PROCEDURE & STANDARDS

Job types and health surveillance needs

These charts are provided to show what screening is required by the different trades and
occupations. However, in practical terms it would be more appropriate if a general screen was
undertaken for all workers with add-ons being provided where there was a particular work related
need identified and linked to an individual.

Job Title

Clinical Examination Required

Duration of
Clinical Exam
20 minutes
With Screening
Technician /
OHA

Administrator (site)

Mid Range Acuity DSE users)

Asbestos Licensed
Worker

Pre-placement Health Questionnaire

Safety Critical Workers Fitness for Task Assessment
Statutory Medicals (Appointed Doctor)
Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
HAVs Assessment
Blood Pressure
Urinalysis

1 hour 30 min
With Screening
Technician /
OHA

Bricklayer

Pre-placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
HAVs Assessment
Work at Height Assessment (balance)

1 hour 30 min
With Screening
Technician /
OHA

Bricklayers Labourer

Pre-placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
HAVs Assessment
Work at Height Assessment (balance)

1 hour 30 min
With Screening
Technician /
OHA

Carpenter / Joiner /
Shopfitter

Pre-placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
HAVs Assessment
Blood Pressure
Urinalysis

1 hour 30 min
With Screening
Technician /
OHA

Page 56 of 63

Job Title
Construction Site
Operative Specialist

Demolition Operative

Electrician Fitter /
Engineer

Form Worker

Clinical Examination Required

Pre-placement Health Questionnaire
Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
HAVs Assessment
Blood Pressure
Urinalysis
Pre-placement Health Questionnaire
Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
HAVs Assessment
Blood Pressure
Urinalysis
Pre-placement Health Questionnaire
Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
HAVs Assessment
Colour Vision
Blood Pressure
Urinalysis
Pre-placement Health Questionnaire
Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
HAVs Assessment Tiers
Blood Pressure
Urinalysis

Duration of
Clinical Exam
1 hour 30 min
With Screening
Technician /
OHA

1 hour 30 min
With Screening
Technician /
OHA

1 hour 30 min
With Screening
Technician /
OHA

1 hour 30 min
With Screening
Technician /
OHA

Glazing / Glass Fitter /

Window Installer

Pre-placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
HAVs Assessment
Blood Pressure
Urinalysis

1 hour 30 min
With Screening
Technician /
OHA

Grounds Person

Pre-placement Health Questionnaire

Audiometry & Questionnaire
HAVs Surveillance
Skin Health Assessment
Mobility Check
Respiratory Surveillance
Blood Pressure
Urinalysis

1 hour 30 min
With Screening
Technician /
OHA

Page 57 of 63

Job Title

Clinical Examination Required

Duration of
Clinical Exam
1 hour 30 min
With Screening
Technician /
OHA

Handyman

Pre-placement Health Questionnaire

Audiometry & Questionnaire
HAVs Screening
Skin Check
Mobility Check
Respiratory Surveillance
Blood Pressure
Urinalysis

Laminator

Audiometry & Questionnaire

Respiratory Surveillance
HAVs Screening
Skin Health Assessment
Mobility Check
Blood Pressure
Urinalysis

1 hour 30 min
With Screening
Technician /
OHA

LGV / HGC Driver

Pre-Placement Health assessment

Assessment
Musculoskeletal Questionnaire / Assessment
Audiometry & Questionnaire
Blood Pressure
Urinalysis
Visual Acuity & Fields
Drug & Alcohol Testing

2 hours
With Screening
Technician /
OHA

Painter / Decorator

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
HAVs Assessment
Blood Pressure
Urinalysis

1 hour 30 min
With Screening
Technician /
OHA

Piling Operative

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Audiometry & Questionnaire
HAVs Assessment
Blood Pressure
Urinalysis
Drug & Alcohol Testing
Pre-Placement Health Questionnaire
Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
HAVs Assessment
Blood Pressure
Urinalysis

2 hours
With Screening
Technician /
OHA

Pipefitter

1 hour 30 min
With Screening
Technician /
OHA

Page 58 of 63

Job Title

Clinical Examination Required

Duration of
Clinical Exam
2 hours
With Screening
Technician /
OHA

Plant Operator - General

Pre-Placement Health Assessment

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Audiometry and Questionnaire
Blood Pressure
Urinalysis
Visual Acuity & Fields
Drug & Alcohol Testing

Plant Operative Crane

Driver

Pre-Placement Health Assessment

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Blood Pressure
Urinalysis
Visual Acuity & Fields
Drug & Alcohol Testing

2 hours
With Screening
Technician /
OHA With OHA

Plant Operative Mobile

Machine Driver

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Audiometry and Questionnaire
Blood Pressure
Urinalysis
Visual Acuity & Fields
Drug & Alcohol Testing

2 hours
With Screening
Technician /
OHA

Plasterer / Dry Liner

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
HAVs Assessment
Blood Pressure
Urinalysis

1 hour
With Screening
Technician /
OHA

Plumber / Gas / Heating /

Ventilation Engineer

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
HAVs Assessment
Blood Pressure
Urinalysis

1 hour
With Screening
Technician /
OHA

Page 59 of 63

Job Title

Clinical Examination Required

Duration of
Clinical Exam
2 hours
With Screening
Technician /
OHA

Rail Trackside

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry and Questionnaire
HAVs Assessment
Blood Pressure
Urinalysis
Visual Acuity & Fields
Drug & Alcohol Testing

Road Construction
Asphalter / Paver

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry and Questionnaire
HAVs Assessment
Blood Pressure
Urinalysis
Visual Acuity & Fields

2 hours
With Screening
Technician /
OHA

Roadside (high speed)

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry and Questionnaire
HAVs Assessment Tiers
Blood Pressure
Urinalysis
Visual Acuity & Fields

2 hours
With Screening
Technician /
OHA

Roofer Slater / Thatcher

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
HAVs Assessment
Blood Pressure
Urinalysis
Visual Acuity & Fields
Drug & Alcohol Testing
Work at Height Assessment (balance)
Pre-Placement Health Questionnaire
Musculoskeletal Questionnaire / Assessment
Blood Pressure
Urinalysis
Respiratory Surveillance
Visual Acuity & Fields
Drug & Alcohol Testing
HAVs Assessment
Work at Height Assessment (balance)

2 hours
With Screening
Technician /
OHA

Scaffolder / Rigger

2 hours
With Screening
Technician /
OHA

Page 60 of 63

Job Title

Clinical Examination Required

Duration of
Clinical Exam
2 hours
With Screening
Technician /
OHA

Site Foreman / Supervisor

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry and Questionnaire
HAVs Assessment Tiers
Blood Pressure
Urinalysis
Visual Acuity & Fields

Site Manager

Pre-Placement Health Questionnaire

Respiratory Surveillance
Audiometry and Questionnaire
Blood Pressure
Urinalysis

1 hour
With Screening
Technician /
OHA

Steel Erector Structural /

Fabricator

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Respiratory Surveillance
Audiometry and Questionnaire
HAVs Assessment Tiers 1-5
Blood Pressure
Urinalysis
Drug & Alcohol Testing

2 hours
With Screening
Technician /
OHA

Steeplejack

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Respiratory Surveillance
Blood Pressure
Urinalysis
Drug & Alcohol Testing

1 hour
With Screening
Technician /
OHA

Stonemason

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry and Questionnaire
HAVs Assessment Tiers

1 hour
With Screening
Technician /
OHA

Telescopic Handler

Pre-Placement Health Questionnaire

Mobile Equipment
Driver
Respiratory Surveillance
Blood Pressure
Audiometry and Questionnaire
Drug & Alcohol Testing

1 hour
With Screening
Technician /
OHA

Page 61 of 63

Job Title

Clinical Examination Required

Duration of
Clinical Exam
45 Minutes
With Screening
Technician /
OHA

Tiler Floor / Wall

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
HAVs Assessment
Blood Pressure
Urinalysis

Tunnel Worker
(confined space /
breathing apparatus

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
HAVs Assessment
Blood Pressure
Urinalysis
Drug & Alcohol Testing

2 hours
With Screening
Technician /
OHA

Welder

Pre-Placement Health Questionnaire

Musculoskeletal Questionnaire / Assessment
Skin Health Assessment
Respiratory Surveillance
Audiometry & Questionnaire
Visual Acuity & Fields
Blood Pressure
Urinalysis

1 hour 30 mins
With Screening
Technician /
OHA

The timing for each medical will depend on any medical issues that may
come to light during the initial assessment.

Page 62 of 63

There are many leaflets and booklets to help an individual. As guidance the following
have been listed:
Title
Man Mini Manual
Publisher Haynes
Title
Woman Manual
Publisher Haynes
ISBN 978-1-84425 1827
Title
Occupational Health
Publisher Blackwell Publishing
ISNBN 1 405 12221- 8

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