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Last Updated

Asbestos Exposure Form

Asbestos Exposure Form

1.

Employment
(1-a) Length of Employment at UWA
from (please choose a year)
(1-b) to
(please choose a year)
(1-c) Length of perceived exposure in months
Length of perceived exposure in months
(1-d) Employment
Were you specifically employed to cut, saw and/or machine asbestos?
 yes no
(1-e) W
Were you specifically employed within an area where asbestos roofing/insultaion and or ventilation material was used in construction.
(1-f) If so, how many months
(1-g) Which Building
If so, which building where you specifically employed in? (you may choose more than one building if applicable)
(1-h) Proximity
(1-i) Advised
Where you told that you were working with or near asbestos?
 yes
 no
(1-j) Advised by whom?
If so, who told you you where working with or near asbestos?
(1-k) Labelling
Were the asbestos-containing materials labelled as such?
 yes no
(1-l) Question (1-l)

2.

Diagnosis
Has there been a diagnosis of:

(2-a) Asbestosis
 yes no
(2-b) Lung cancer
 yes no
(2-c) Mesothelioma
 yes no

3.

Work History
During your employment by UWA have you worked in any of the occupations below?

(3-a) Boilmaker
 yes no
(3-b) Brickmason
 yes no
(3-c) Operator
 yes no
(3-d) Pipefitter
 yes no
(3-e) Welder
 yes no
(3-f) Steelworker
 yes no
(3-g) Insulator
 yes no
(3-h) Electrician
 yes no
(3-i) Millwright
 yes no
(3-j) Carpenter
 yes no
(3-k) Maintenance Mechanic
 yes no
(3-l) Sandblaster
 yes no
(3-m) Machinist
 yes no
(3-n) Grinder
 yes no
(3-o) Labourer
 yes no
(3-p) Operating Engineers
 yes no
(3-q) Question (3-q)
Please describe how you came to be exposed to asbestos
(3-r) Plumber
 yes no
(3-s) Steamfitter
 yes no
(3-t) Cement Plant Worker
 yes no
(3-u) Construction Worker
 yes no
(3-v) Chemical Plant Worker
 yes no
(3-w) Furnace Worker
 yes no
(3-x) Sheet Metal Worker
 yes no
(3-y) Utility Worker
 yes no
(3-z) Heating Technician
 yes no
(3-aa) Heating & Airconditioning Technician
 yes no
(3-ab) Other
Please describe:

4.

Exposure

(4-a) Known Exposure
List any materials you handle, or which are used near you as you work, which contain asbestos:
(4-b) Usual work done
Include all the different work you do, in different parts of the workplace as necessary:
(4-c) Monitoring
Were air samples taken? How often? By people you recognised? Were you told the results?:
(4-d) Indirect Contact
Other work with asbestos at or near your workplace (List any jobs done at your workplace which involve asbestos exposure even if you are not directly in contact with them):
(4-e) Possible Exposure
List any materials you handle, or which are used near you as you work, which you think might contain asbestos:
(4-f) Witnesses
Were there any witnesses to the exposure?
 yes no
(4-g) If Witnesses
If there were witness(es) please state full name and date of birth
(4-h) Environment
Was the exposure Indoors or Outdoors?
 Indoors Outdoors
(4-i) Ventilation
Was the area ventilated eg where the windows and/or doors open?
 yes no

5.

Exposure Activities
Where you:

(5-a) Plumbing
Insulating or lagging boilers?
 yes no
(5-b) Electrical
Manufacturing or maintaining brakes or clutches?
 yes no
(5-c) Insulation
Spraying Insulation
 yes no
(5-d) Cutting
Repeatedly cutting asbestos board?
 yes no
(5-e) Construction
construction or demolition
 yes no
(5-f) Removing
Removing asbestos
 yes no
(5-g) Other Exposures
Please describe (eg washing an exposed persons overalls)
(5-h) Question (6-i)
(5-i) Question (6-j)

6.

Personal Details
(6-a) Last Name
(6-b) Given Names
(6-c) Date of Birth
(6-d) Telephone Home
(6-e) Telephone Work
(6-f) Email address
(6-g) Home Address
(6-h) Diagnosis Occurance
When did diagnosis occur? Select 2002 2001 2000 1999 1998 1997 1996
(6-i) Question (4-o)
Why do you believe exposure occured there?
(6-j) Question (4-p)
Protection from exposure (List any protection you were given, including masks and/or respirators (include type), special work clothing, showers, protected eating areas, etc.):
(6-k) Question (4-q)
Please describe where you think exposure may have occurred
(6-l) Question (4-r)
What was occupation at time of exposure:
(6-m) Question (4-s)
Describe other injuries or effects from asbestos exposure:
(6-n) Question (4-t)
I agree that I am an employee of UWA and I have completed this form honestly
 yes no
(6-o) Question (4-y)
Pleural Plaques
 
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