Beruflich Dokumente
Kultur Dokumente
__________
__________
__________
2nd Shift
__________
__________
__________
3rd Shift
__________
__________
__________
d.
The occupational health physician/practitioner/nurse/personnel conducts an inspection of
the workplace:
( )
once every month
( )
once every three (3) months
( )
once every two (2) months
( )
once every six (6) months
( )
other details ____________________________________________________________
8. Emergency Occupational Health Services:
a. The employer provides a treatment room/medical clinic in the workplace with medicines and
facilities:
( )
yes
( )
no
( )
others, please specify _____________________________________________________
_______________________________________________________________________
b. Schedule of attendance in the workplace:
Work shift
Occupational health physician
Occupational health dentist
Occupational health practitioner
Occupational health nurse
c.
d. The following occupational health personnel of the establishment have undergone training in
occupational health and safety/first aid:
( )
occupational health physician
( )
occupational health dentist
( )
occupational health nurse
( )
first aider
( )
others, please specify _____________________________________________________
_______________________________________________________________________
9. Occupational Health Services:
a. The occupational health personnel of this establishment conducts regular appraisal of the
sanitation system in the workplace::
( )
yes
( )
no
b. Number of workers who underwent the following medical examination:
Physical Exam
X-Rays
Urinalysis
1. Pre-placement
______________
_____________
________________
2. Periodic
______________
_____________
________________
3. Return-to-work
______________
_____________
________________
4. Transfer
______________
_____________
________________
5. Special
______________
_____________
________________
6 Separation
______________
_____________
________________
1.
2.
3.
4.
5.
6.
Pre-placement
Periodic
Return-to-work
Transfer
Special
Separation
Stool Exam
__________
__________
__________
__________
__________
__________
Blood Test
__________
__________
__________
__________
__________
__________
ECG
________
________
________
________
________
________
Others
__________
__________
__________
__________
__________
__________
Female
Total Number
of Cases
Skin:
(
(
(
)
)
)
_______
_______
_______
_______
___________
___________
allergy
dermatoses
infection as folliculitis
abscess/paro nychia
Others
_______
_______
_______
_______
___________
___________
(
(
)
)
tension headache
Others
_______
_______
_______
_______
___________
___________
(
(
)
)
error of refraction
bacterial/viral
conjunctivities
cataract
Others
_______
_______
___________
_______
_______
_______
_______
_______
_______
___________
___________
___________
Gingivitis
Herpes labiales/nasalis
Otitis Media/Externa
Deafness
Menleres Syndrome/Vertigo
Rhinitis/Colds
Nasal Polyps
Sinusitis
Tonsillopharyngitis
Laryngitis
Others
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
Bronchitis
Bronchial asthma
_______
_______
_______
_______
___________
___________
Head:
Eyes:
( )
( )
Mouth & ENT:
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
Respiratory:
( )
( )
( )
Pneumonia
( )
Tuberculosis
( )
Pneumoconiosis
( )
Others
Heart and Blood Vessel:
( )
Hypertension
( )
Hypotension
( )
Angina Pectoria
( )
Myocardial Infraction
( )
Vascular disturbances in
extremeties due to
continuous vibration
( )
Others
Gastrointestinal:
( )
gastroenteritis/darrhea
( )
amoebiasis
( )
gastritis/hyperacidity
( )
appendicitis
( )
infectious hepatitis
( )
liver cirrhosis
( )
hepatic abscess
( )
cancer (hepatic/gastric)
( )
ulcer
( )
Others
Genito Urinary:
( )
Urinary tract infection
( )
Stones
( )
Cancer
( )
Others
Reproductive:
( )
Dysmenorrhea
( )
Infection (Cervicitis)
(vaginitis)
( )
Abortion (Spontaneous)
(Threatened)
( )
Hyperemesis Gravidarium
( )
Uterine Tumors
( )
Cervical Polyp/Cancer
( )
Ovarian Cyst/Tumors
( )
Sexually-Transmitted
diseases
( )
Hernia (Inguinal)
(Femoral)
( )
Others
Neuromuscular/Skeletal/Joints:
( )
Peripheral Neuritis
( )
Torticollis
( )
Arthritis
( )
Others
Lymphatics and Circulatory:
( )
Anemia
( )
Leukemia
( )
Cerebrovascular Accidents
( )
Lymphadenitis
___________
( )
Lymphoma
Infectious Diseases:
( )
Influenza
( )
Typhoid/paratyphoid fever
( )
Cholera
( )
Measles
( )
tetanus
( )
Malaria
( )
Schistosomiasis
( )
Herpes Zoster
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
__________
___________
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
_______
_______
_______
_______
___________
___________
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
Male
Female
Total Number
Of Cases
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
___________
___________
___________
___________
___________
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
_______
_______
___________
_______
_______
___________
_______
_______
___________
_______
_______
_______
_______
___________
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
___________
___________
___________
___________
(
(
(
(
)
)
)
)
Chicken Pox
German Measles
Rabies
Others
c)
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
_______
_______
_______
_______
___________
___________
_______
_______
_______
_______
___________
___________
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
___________
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
___________
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
___________
Male
Female
Total Number
of Cases
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
___________
Male
Female
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Number of
Cases
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
Male
Female
Total
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
___________
___________
___________
___________
___________
___________
d)
done
not done
14. Health Education and Counselling by Health and Safety Personnel: (Please check one ormore)
(
(
(
)
)
)
Seminar
Use of Visual
Aid/Materials
Counselling
Nutrition Program
Maternal and Child Care Program
Family Planning Program
Mental Health Activities
Personal Health Maintenance
Physical fitness Program: (Please check)
Sports Activities
Others (Please specify)
(
(
)
)
Yes
Yes
(
(
)
)
No
No
16. Hazards in the workplace: (Please check and give details of the substance)
Substances and/or
Sources
Number of workers
exposed
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Biological Hazards:
( )
Viral
( )
Bacterial
( )
Fungal
( )
Parasitic
( )
Others
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Ergonomic Stress:
( )
Exhausting physical work
( )
Prolonged standing
( )
Excessive mental effort
( )
Unfavorable work posture
( )
Static/monotonous work
( )
Others, specify
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
a) Chemical Hazards:
( )
dust (Ex. Silica dust)
( )
liquids (Ex. Mercury)
( )
mist/fumes/vapors (Ex. Mist
from paint spraying)
( )
gas (Ex. CO, H2S)
( )
others (please specify)
(Ex. Solvents)
b)
c)
d)
Physical Hazards:
( )
noise
( )
temperature/humidity
( )
pressure
( )
illumination
( )
radiation/ultraviolet/
microwave
( )
vibration
( )
Others (Please specify)
Submitted by:
_______________________________
Medical Personnel/Title
___________________
Date
Noted by:
________________________________
Employer