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Occupational Health Referral Form
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Group Occupational Health Assessments
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Biological effect monitoring request form
Biological monitoring measures how much of a substance has entered the body. Biological Effect Monitoring is appropriate when you need to demonstrate that: - Compliance with a WEL (Workplace Exposure Limit) or BMGV ( Biological Monitoring Guidance Value) - Control equipment or personal protective equipment is working well enough By completing this form, you confirm that you are requesting biological monitoring for exposure assessment to evaluate and support measures taken under the COSHH Regulations, where ALL of the following apply: - The results will give you information in addition to that already available through complying with the COSHH Regulations; - The results will provide you with useful information on exposure assessment which will help in evaluating control measures; - There is an appropriate sampling strategy and analytical technique which preferably involves non-invasive sampling (ie urine or breath rather than blood); - You have clear criteria for interpreting the results or you agree to contracting Workability Solutions to interpret and advise you; - You have the relevant experience and knowledge to act on it; or you agree to appoint a suitably qualified and competent person to do so on your behalf; - You agree to Workability Solutions contracting the appropriate specialist expertise able to act on it; - Where blood samples are unavoidable you agree to Workability Solutions appointing an appropriately qualified person to take them
Please enable JavaScript in your browser to complete this form.
Employer details
*
First
Middle
Last
Background context, information and reason for request
*
Tell us why you are requesting biological monitoring, e.g. COSHH assessment including hazards identified on product data sheets, Health surveillance results, HSE inspection, Occupational Hygiene report. This might include clusters of symptoms, ill-health trends and/or results of lung function tests and/or skin checks.
Email
*
Email
Confirm Email
This should be the email of the budget holder to ensure swift processing of your request.
How do the COSHH risk assessments show that substances may enter the body?
Breathing in contaminated air (inhalation), including availability and compliance with respiratory protective equipment
Hand-to-mouth (ingestion), including availability and compliance with hand-washing
Skin absorption through uncovered skin or ineffective protective clothing
Check your material safety data sheets to find out how your employees may absorb chemicals and hazardous substances.
All hazardous exposures in use within the workplace (laboratory scientists need to know this)
*
Animal pathogens (
https://www.hse.gov.uk/biosafety/sapo/notify.htm
)
Bloodborne viruses (
https://www.hse.gov.uk/biosafety/blood-borne-viruses/how-deal-exposure-incident.htm
)
Butan-2-one (BGMV)
2-Butoxyethanol (BGMV)
Cadmium
Carbon monoxide
Chlorobenzene (BGMV)
Chromium IV (BGMV)
Cobalt
Cyclohexanone (BGMV)
Dichloromethane (BGMV)
N,N-Dimethylacetamide (BGMV)
Glycerol Trinitrate (Nitroglycerine) (BGMV)
Isocyanates: HDI, IPDI, MDI, TDI (BGMV)
Lead
Lindane [GBHC (ISO)] (BGMV)
MbOCA (2,2-dicholoro 4,4' methylene dianiline) (BGMV)
Mercury (BGMV)
Methyl bromide
4,4’-Methylenebis-(2-chloroaniline) (BGMV)
4-Methylpentan-2-one (BGMV)
4,4'-methylenedianiline- (MDA) (BGMV)
Nickel
Polychlorinated biphenyls (BGMV)
Polycyclic Aromatic Hydrocarbons (PAH) (BGMV)
Styrene
Tetrachloroethylene
Xylene (BGMV)
I'm not sure - I want to book a health risk assessment
Select ALL the hazardous exposures in the workplace where your reason for biological monitoring applies.
Which hazardous exposure(s) do you need to carry out biological monitoring for?
*
Animal pathogens (
https://www.hse.gov.uk/biosafety/sapo/notify.htm
)
Bloodborne viruses (
https://www.hse.gov.uk/biosafety/blood-borne-viruses/how-deal-exposure-incident.htm
)
Butan-2-one (BGMV)
2-Butoxyethanol (BGMV)
Cadmium
Carbon monoxide
Chlorobenzene (BGMV)
Chromium IV (BGMV)
Cobalt
Cyclohexanone (BGMV)
Dichloromethane (BGMV)
N,N-Dimethylacetamide (BGMV)
Glycerol Trinitrate (Nitroglycerine) (BGMV)
Isocyanates: HDI, IPDI, MDI, TDI (BGMV)
Lead
Lindane [GBHC (ISO)] (BGMV)
MbOCA (2,2-dicholoro 4,4' methylene dianiline) (BGMV)
Mercury (BGMV)
Methyl bromide
4,4’-Methylenebis-(2-chloroaniline) (BGMV)
4-Methylpentan-2-one (BGMV)
4,4'-methylenedianiline- (MDA) (BGMV)
Nickel
Polychlorinated biphenyls (BGMV)
Polycyclic Aromatic Hydrocarbons (PAH) (BGMV)
Styrene
Tetrachloroethylene
Xylene (BGMV)
I'm not sure - I want to book a health risk assessment
Select ONLY the hazardous exposures in the workplace that you want to test for.
use (if Background
Test required (if known)
Blood test (only if urine test not available)
Breath test
Urine test
I'm not sure - I would like to book an advice call*
Use the text box above to tell us anonymised information about any clusters of symptoms or health trends and results of lung function tests and/or skin checks or that you are concerned about.
Submit my request for biological monitoring