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Lead Health Surveillance Record

Author: Novade Solutions

Use this Lead Health Surveillance Record template to record information of personnel exposed to lead.

Published on: 7/15/2021

Lead health surveillance record

Employee’s details

Surname

Maiden name (if applicable)

Forenames

Gender

Permanent address

Date of birth

Place of birth

National Insurance no.

NHS no. (if available)

Doctor’s (GP) details

Name

Address

Telephone no.

Employer’s details

Name

Address

Telephone number

Standard IndustrialClassification (SIC no.)

Employment details

Years exposed to lead before starting incurrent employment

Date of first exposure to lead in current employment (day/month/year)

Date of end of exposure to lead in current employment (day/month/year

Additional information

The reason for medical surveillance

The dates of initial and periodic medical surveillance

The results of clinical assessments

The results of measuring blood-lead concentrations and of any other biological tests in enough detail to allow adverse trends to be identified

Action taken and required suspension period(s) from work involving lead.

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Lead health surveillance record

Employee’s details

Surname

Maiden name (if applicable)

Forenames

Gender

Permanent address

Date of birth

Place of birth

National Insurance no.

NHS no. (if available)

Doctor’s (GP) details

Name

Address

Telephone no.

Employer’s details

Name

Address

Telephone number

Standard IndustrialClassification (SIC no.)

Employment details

Years exposed to lead before starting incurrent employment

Date of first exposure to lead in current employment (day/month/year)

Date of end of exposure to lead in current employment (day/month/year

Additional information

The reason for medical surveillance

The dates of initial and periodic medical surveillance

The results of clinical assessments

The results of measuring blood-lead concentrations and of any other biological tests in enough detail to allow adverse trends to be identified

Action taken and required suspension period(s) from work involving lead.