Confidential Health Assessment Form Coal Mine Workers ...

Confidential Health Assessment Form Coal Mine Workers Health Scheme (Form approved under section 281 of the Coal Mining Safety and Health Act 1999) Name (Full Given Name(s) and Family Name) Date of Birth Privacy Obligations Health surveillance information is collected by the Department of Mines and Energy for the purpose of conducting research on the identification of conditions which are present in coal mine Workers . This work will enable further research into the causes and management of these conditions. It is collected under the authority of Part 6 Division 2 of the Coal Mining Safety and Health Regulation 2001. The Department will not disclose this information to any person except in accordance with the Regulation. The Regulation requires that your identity be protected when information is disclosed for research purposes. The results of research assist in improving the occupational Health of coal mine Workers .

Section 1 – Employer to complete Name of Nominated Medical Adviser Employer Coal Worker’s Position - (provide generic job title) Mine (e.g. Southern Colliery if applicable) (a) Is the coal mine worker at risk from dust exposure (x-ray needed)?

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