JOB HAZARD EVALUATION FORM
This form should be completed by the recruiting officer/supervisor to identify if a health assessment in relation to work exposures is required.  If the person’s work involves exposure to one of the hazards indicated on this form, please forward the completed form to Occupational Health.  If no hazards are identified do not send the form to Occupational Health, please keep the form in the employee/students file in the department.  
Tel: 01223 336594.  Email:  occhealth@admin.cam.ac.uk  

Surname:		Mr / Mrs / Miss / Ms / Dr / Prof / Other	
First names:		Date of Birth:		
Job title:		Start date:		
Status: 	Research staff / Technical staff / Undergraduate / Postgraduate / Academic Visitor / Administrative / Academic / Other 	
Mobile:		Email:		
Department:		Recruiter/ supervisor:		
Recruiter/ supervisor’s email :		Recruiter/ supervisor’s tel:		
Form completed by		Post title:		

Please indicate whether this person’s job will involve work with any of the following:	Further information 	
1.	Animals, including farm animals, insects and birds
	If yes please indicate species below
	Yes  No
	Include anyone who may have indirect contact, e.g., through location of office/laboratory in relation to the animal facility, include domestic (farm animals and birds).  Enrolment on the Animal Allergy (AA) health surveillance programme will be necessary on commencement of employment
	
2.	Deliberate handling of pathogens or GMOs in containment level 3 facilities
	If yes please give name of the pathogen(s) & 	forward copies of the risk assessment
	Yes  No	If the person will be intentionally culturing or handling cultures of Hazard Group 3 pathogens or GMOs classified as class 3 projects on the basis of their risk to human health. An occupational health assessment is required prior to commencing this work
	
3.	Unscreened human tissue and /or blood	Yes  No	If ‘yes’ please forward copies of documentary evidence of your hepatitis B immunisation vaccination records and blood test results (e.g. GP print out and/or vaccination record book)
	
If a Research Passport is needed please contact your HR Adviser to initiate this process
	
4.	Work with ionising radiation that requires formal Classification of the individual as confirmed by a University Radiation Protection Adviser within your department or Safety Office	Yes  No	Work with radioactive substances or machine generators, that is, , likely to result in the individual receiving, in any year, an ionising radiation dose three tenths that of any statutory radiation dose limit.  A medical assessment is required prior to commencing classified radiation work.
	
PLEASE TURN 0VER TO COMPLETE FORM.  FORM MAY BE RETURNED IF NEXT PAGE NOT COMPLETED	
5.	Respiratory/skin sensitisers e.g. solder flux, latex, isocyanates, wood dust, glues and resins.
Please forward copies of the risk assessments associated with this work exposure
	Yes  No	As identified through risk assessment.  Please forward copies of the risk assessments associated with this work exposure
	
6.	Toxic metals e.g. lead, mercury, thallium - Please forward copies of the risk assessments associated with this work exposure
	Yes  No	As identified through risk assessment. Please forward copies of the risk assessments associated with this work exposure
	
7.	Driving fork lift trucks
	Yes  No	Use of mechanised pallet trucks/fork lifts trucks only.
	
8.	Regular exposure to noise at an action level that requires surveillance as identified through noise measurement assessment undertaken by the Safety Office
	Yes  No	Please forward copies of the risk assessments and noise measurement assessments associated with this work exposure.
	
9.	Regular use of vibrating tools at an action level that requires surveillance as identified through HAVS measurement assessment undertaken by the Safety Office
	Yes  No	Please forward copies of the risk assessments and HAVS measurement assessments associated with this work exposure
	
10.	Night work (between 2300 and 0600hrs inclusive)
	Yes  No	Regular work of at least 3 hours during the night period 23:00hrs and 06:00hrs only - not working late in the evening	
11.	Food handling	Yes  No	The person’s work involves the preparation of uncooked food, e.g. chefs, not the handling of wrapped food, e.g. sandwiches and biscuits.
	
12.	Other  - Please specify	Yes  No	Answer ‘yes’ if the job requires a specific health assessment to meet the requirements of a joint employer or work placement or specific infection control measures.  Please forward copies of the risk assessments associated with this exposure.

For occupational health use only

Name_______________________________________Date_______________________