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Step 1 of 3


Date of Birth
Date started employment:

Past employment history

Please note: If you answer 'yes' to any of the questions, the doctor will discuss them further during your consultation. You are not required to provide additional comments.

Have you ever worked in any of the following jobs?
1 Excavation/earth moving
2 Drilling Plant
3 Clay/stone processing
4 Paving/surfacing
5 Mining
6 Construction
7 Abrasive blasting
8 Foundry casting
9 Natural or composite stone cutting
10 Manufacturing or installing composite stone
11 Working with refractory bricks – furnace linings
12 Other (please specify)

Past occupational exposure

For initial examination, please complete details for the four dustiest jobs listed above by duplicating this page as many times as is required

3. Job description:

Include information on silica work tasks and the length of exposure that may impact health of the worker.

For example: - Shaping e.g. with powered hand tools - Sawing e.g. with bridge saw - Polishing/finishing - General labouring - Maintenance - Cleaning the tools, surfaces and/or work space etc.
4. Silica description:

Include information on type of silica that the worker might be exposed.

For example: - Composite stone - Naturals - Granite - Shale - Aggregates, mortar and concrete etc. - Refractory bricks - Other (please specify)
5. Controls used at the workplace:

Include information on control methods used during tasks.

For example ventilation: - On the tools - At the bench - In the ceiling - Open window/door etc.
6. Administrative controls used at the workplace:

Include information if any administrative controls are in place to provide extra protection.

7. Personal protective equipment (PPE) used at the workplace:

Include information on PPE used

For example: - Paper/disposable - Half face - Full face etc.