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Asbestos Exposure Form

Asbestos exposure form

Personal details

Family name Given names Date of birth Mobile number Telephone (work) Email address Home address

Working at UWA

Are you staff or contractor?

Working status?

Are you currently working / studying at UWA (at time of reporting)?

Working / Studying at UWA Yes No

Building Details

What building?

Enter the address of the building e.g. 22 Hobbs Avenue and the room number. Other pertinant information

Exposure

Known exposure. List any materials you handle, or which are used near you as you work, which contain asbestos.

Usual work done

Include all the different work you do, in different parts of the workplace as necessary:

Monitoring

Were air samples taken? How often? By people you recognised? By engaged asbestos assessor? Were you told the results?

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).

Possible exposure

List any materials you handle, or which are used near you as you work, which you think might contain asbestos.

Witnesses

Were there any witnesses to the exposure? Yes No If there were witness(es) please state full name and date of birth.

Environment

Was the exposure indoors or outdoors? Indoors Outdoors

Ventilation

Was the area ventilated eg where the windows and/or doors open? Yes No

Reporting date

When was exposure reported into UWA Electronic Incident Reporting System / UWA Safety / UWA IMW Camms Reference Number

Camms https://uniwa.sharepoint.com/sites/sd-Safety/SitePages/Report-a-safety-hazard,-incident-or-near-miss.aspx

Exposure activities

What Activity Exposed you to respirable asbestos fibres?

What were you doing, occupation, the ACM its condition etc..

Plumbing (Insulating or lagging boilers?) Yes No Electrical (Manufacturing or maintaining brakes or clutches?) Yes No Insulation (Spraying insulation?) Yes No Cutting (Repeatedly cutting asbestos board?) Yes No Construction (Construction or demolition?) Yes No Removing asbestos? Yes No

Please describe eg washing an exposed persons' overalls.

Other activities

Were you told that you were working with or near asbestos?

Advised Yes No

If so, who advised you that you that you were working with or near asbestos?

Advised by whom?

Provide details of any warning labels or stickers in the area.

Labelling

Where located at the time of exposure.

Proximity

This only relates to exposure at UWA.

Length of perceived exposure in months

Health Surveillance / Medical Advice

Have you undergone testing e.g. a low dose CT Scan, X-ray, lung function test etc? If yes please go to next question. Yes No

Please provide more information on the tests you have undergone.

More Information

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35 Stirling Highway
Perth WA 6009 Australia

(+61 8) 6488 6000

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(+61 8) 6488 2222

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The University of Western Australia acknowledges that its campus is situated on Noongar land, and that Noongar people remain the spiritual and cultural custodians of their land, and continue to practise their values, languages, beliefs and knowledge.

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