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HSE HAVS Assessment Template

Use this template for your workers to answer 12 HSE HAVS assessment questions, including their occupational history, and automatically gain actionable insights via Lumiform analytics.
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HSE HAVS Assessment Template

Inspection

HSE HAVS Assessment

MEDICAL IN CONFIDENCE

Have you ever used hand-held vibrating tools, machines or hand-fed processes in your job?

Indicate the year of first exposure

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

Do you have tingling of the fingers at any other time?

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

Do one or more of your fingers go numb more than 20 minutes after using vibrating equipment?

Have your fingers gone white on cold exposure?

Do you have difficulty rewarming them when leaving the cold?

Whiteness means a clear discoloration of the fingers with a sharp edge, usually followed by a red flush.

Do your fingers go white at any other time?

Are you experiencing any other problems with the muscles or joints of the hands or arms?

Do you have difficulty picking up very small objects, e.g. screws or buttons or opening tight jars?

Have you ever had a neck, arm or hand injury or operation?

Give details

Have you ever had any serious diseases of joints, skin, nerves, heart or blood vessels?

Give details

Are you on any long-term medication?

Give details

Occupational History

Job Title

Job Title

Start Date

End Date

Completion

I certify that all the answers given above are true to the best of my knowledge and belief.

Full Name and Signature of Employee

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