Hand Arm Vibration Level 2

Employee Details

Full Name (required)

DOB (required)//

Job Title (required)

Employer (required)

Address (required)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone (required)

Have you been using handheld vibrating tools, machines or hand-fed processes in your job in the last two years? (required)

Yes
No

If no please complete the declaration below and submit

1. Do you have any numbness or tingling of the fingers lasting more than 20 minutes after using vibrating equipment?

Yes
No

2. Do you have numbness or tingling of the fingers at any other time?

Yes
No

3. Do you wake at night with pain, tingling, or numbness in your hand or wrist?

Yes
No

4. Have any of your fingers gone white* on cold exposure? *Whiteness means a clear discoloration of the fingers with a sharp edge, usually followed by a red flush.

Yes
No

5. Have you noticed any change in your response to your tolerance of working outdoors in the cold?

Yes
No

6. Do you have difficulty picking up very small objects eg screws or buttons or opening tight jars?

Yes
No

7. Are you experiencing any other problems in your hands or arms?

Yes
No

8. Has anything changed about your health since the last assessment?

Yes
No

If answers are Yes to questions 1-6 please complete full assessment questionnaire

Declaration

I declare that the answers given in this form are true to the best of my knowledge and belief. I consent to information regarding my fitness to use vibrating tools or machinery being passed to my employer. I consent to ExeMed processing and holding this information under the Data Protection Legislation.

Date