cmshr 1 health assessment form · department of natural resources, mines and energy form cmshr 1...

Department of Natural Resources, Mines and Energy

Form CMSHR 1 – Health assessment form Version 5 – effective 1 March 2019 of 26 This form was approved by the chief inspector under section 281 of the Coal Mining Safety and Health Act 1999

CMSHR 1 – Health assessment form Section 46A, Coal Mining Safety and Health Regulation 2017

Family name

First name Middle name Date of birth

Instructions for completing the health assessment

Employer must:

Complete Section 1.

Arrange and pay for the health assessment of the Coal Mine Worker (the worker).

Ensure the health assessment is carried out or supervised by an Appointed Medical Adviser (AMA) appointed under contract by the employer and registered with the Department of Natural Resources, Mines and Energy (DNRME) as an approved supervising doctor.

Provide Section 1 to the Examining Medical Officer (EMO) prior to the health assessment.

Worker must:

Bring photo identification to be confirmed by the EMO.

Complete Section 2, including work history as follows: o if the worker is commencing work in the industry – must provide full previous work history; or o if the worker is already employed in the industry – must provide work history since last health assessment.

Attach a separate statement if space on form is insufficient (e.g. for work history).

Complete the consent and declaration components of Section 2.

EMO/AMA must (if undertaking medical examination):

Be registered with DNRME as an approved examining or supervising doctor.

Confirm photo identification provided by the worker. (NOTE: The examination must not proceed if photo identification is not supplied by the coal mine worker).

Check that Section 1 has been completed by the employer. (NOTE: The examination must not proceed if Section 1 is not completed by the employer).

Review Section 1 of this form noting and taking advice from the employer about specific position requirements and hazard exposures. (NOTE: A respiratory function examination should be undertaken at every routine periodic health assessment).

Review/complete Section 2 of this form (with the worker as required and comment on any abnormality).

Ensure that the worker completes the consent and declaration components of Section 2.

Ensure that spirometry and chest x-ray examinations are carried out in accordance with the relevant DNRME standards in force at the time.

Ensure that the worker is provided with a chest x-ray referral form that clearly states that the subject is a coal mine worker.

Complete Section 3 (and attach spirometry test results, x-ray report, and ILO classification).

Not complete Section 4 if not the AMA.

AMA must:

Ensure they have been appointed as an AMA by the worker’s employer recorded in Section 1 and are registered as an approved supervising doctor with DNRME (NOTE: The AMA must not complete Section 4 if they have not been appointed as an AMA by the recorded employer and/or are not a registered supervising doctor).

Review Sections 1, 2 and 3.

Ensure the chest x-ray is examined against the ILO International Classification of Radiographs of Pneumoconioses only by a radiologist registered with DNRME.

Ensure that further reading of the chest x-ray has been undertaken by Lungscreen Australia.

Complete Section 4 following the completion of relevant tests and reviews, including any chest x-ray examination and further x-ray reading.

Arrange appropriate additional testing if the worker has abnormal respiratory function or chest x-ray examination results, in accordance with the Coal Mine Workers’ Health Scheme Clinical Pathways Guideline.

Recommend that appropriate practical testing is organised if the worker has an abnormal colour vision or hearing result affecting “fitness for duty”.

Assess whether the assessment provides adequate information to complete Section 4 on the fitness for duty of the worker.

Provide an explanation of Section 4 to the worker.

Provide a copy of Section 4 to (a) the worker at the postal address given in Section 2, or by email if the worker agrees; and (b) the employer.

Promptly forward or upload to the DNRME Health Surveillance Unit, in the approved way stated on the DNRME website, within 28 days: o A digital chest x-ray image file (DICOM) and a copy of the x-ray report (if forwarded, saved to CD/DVD). o A legible copy of the completed health assessment form and the data or information on which it was based; including the spirometry

report and spirogram and/or lung function test reports, ILO classification form, high resolution CT scan report, and any relevant medical specialist reports.

Keep the data on which the assessment or examination was based and a copy of the approved form completed for the assessment, in the approved way and period stated on the DNRME website.

https://www.dnrm.qld.gov.au/__data/assets/pdf_file/0005/1278563/cmwhs-clinical-pathways-guideline.pdf


Form CMSHR 1 – Health assessment form – Section 1 (Employer to complete) Version 5 – effective 1 March 2019 of 26 This form was approved by the chief inspector under section 281 of the Coal Mining Safety and Health Act 1999

Section 1 Employer to complete

1.1 Employer’s details

(a) Business or trading name

(b) Address

(c) Business phone number

(d) Email address

(e) Contact name

(f) Type of employer (Mark one for relationship with this worker)

i. Mine operator

ii. Contractor to one or more mines

iii. Supplier to one or more mines

iv. Labour hire

1.2 Employer’s AMA

(a) Name of AMA

(For this site, if AMA appointment is site specific)

1.3 Worker’s proposed/current position

(a) Position (Refer to position list on the DNRME website1, identify position title)

1 Standardised coal mine worker positions guideline available at: www.dnrm.qld.gov.au/_data/assets/pdf_file/0003/1386048/standardised-coal-mine-worker-positions.pdf

https://www.dnrm.qld.gov.au/__data/assets/pdf_file/0003/1386048/standardised-coal-mine-worker-positions.pdf

https://www.dnrm.qld.gov.au/__data/assets/pdf_file/0003/1386048/standardised-coal-mine-worker-positions.pdf



(b) Similar Exposure Group (SEG) (Refer to SEG information on the DNRME website2)

NOTE: Employer to include all relevant SEGs for the worker. If multiple SEGs apply, list from most commonly to least commonly applicable for that worker.

(c) Name of Mine NOTE: If multiple sites, specify primary mine location at time of health assessment

(d) Coal mine type and work location (Mark one only, most relevant type and location):

i. Underground mine – face

ii. Underground mine – non-face

iii. Underground mine – surface

iv. Aboveground mine

1.4 Reason for health assessment

(Mark only one of (a) – (d))

(a) Person to be employed is: (Mark either i, or all of ii-iv that apply)

i. New entrant to coal mining industry

ii. Commencing work in a different type of position

iii. Commencing work at a new mine (may also be commencing a different type of position)

iv. Commencing work for a new employer (may also be

commencing a different type of position or at a new mine)

(b) AMA considers the assessment is necessary after being given a

notice by the employer under section 49(3)

(c) Periodic health assessment of coal mine worker is required

(d) Subsequent assessment (review) of coal mine worker is required

2 SEG guideline available at: www.dnrm.qld.gov.au/__data/assets/pdf_file/0008/977498/similar-exposure-groups.pdf

https://www.dnrm.qld.gov.au/__data/assets/pdf_file/0008/977498/similar-exposure-groups.pdf

https://www.dnrm.qld.gov.au/__data/assets/pdf_file/0008/977498/similar-exposure-groups.pdf



1.5 Specific coal mine worker position requirements or hazard exposures

(a) The coal mine worker is required to do the following: (Employer to mark all that apply)

None apply

i. Operate heavy mobile equipment

ii. Work around heavy mobile equipment

iii. Work in an underground mine

iv. Work in wet or muddy conditions

v. Work in areas with uneven ground conditions

vi. Work at heights

vii. Work in confined spaces

viii. Ascend/descend ladders

ix. Perform heavy manual handling

x. Self-escape in an emergency situation

xi. Use colour vision to perform job safely

(b) Coal mine worker is, or may be, required to wear or use the following from time to time, depending on conditions (Mark all that apply)

None apply

i. Personal protective equipment (examples: safety helmet, safety glasses, hearing protection, long sleeve shirt and trousers, safety footwear)

ii. Respiratory protective equipment (examples: respirators,

self-rescue breathing device for underground workers)

(c) Coal mine worker may potentially be exposed to (Mark all that apply) None apply

i. Dust:

a. Coal dust

b. Other dust (including dust from silica bearing rock)

c. Asbestos containing materials

d. Diesel exhaust

e. Welding fume

f. Noise greater than 85 decibels and/or a peak of 140dB

g. Whole body vibration (example: truck drivers)

h. Hand arm vibration (example: machine operators)

i. Heat and/or humidity



ii. Chemicals:

a. Oils, greases

b. Solvents

c. Phenols

d. Isocyanates

e. Acids

f. Alkalis

g. Cement, grout, stone dust

h. Detergents, hand cleaners

1.6 Requirement for chest x-ray examinations (Mark only one)

(a) First or baseline chest x-ray (new entrant to coal mining industry)

(b) Periodic chest x-ray (existing coal mine worker, required at

least every 5 years, or lesser period as determined by AMA)


Form CMSHR 1 – Health assessment form – Section 2 (Worker to complete) Version 5 – effective 1 March 2019 of 26 This form was approved by the chief inspector under section 281 of the Coal Mining Safety and Health Act 1999

Section 2 – Coal mine worker to complete

2.1 Coal mine worker’s details

(a) Family name

(b) First name

(c) Middle name

(d) Previous names (if changed since last health assessment)

(e) Date of birth

(f) Sex

Male Female Other

(g) Gender Male Female Other

(h) Home address

(i) Postal address (if different to home address)

(j) Telephone / mobile number

(k) Email address

(l) Medicare number

Individual reference number (Number is located next to each name on Medicare card)

Coal Mine Worker is not enrolled in Medicare



2.2 Position requirements or hazard exposures

Does Section 1.5 of this form include all the requirements and hazard exposures for your current/proposed position? Yes No

If No, outline the additional requirements/exposures

2.3 Work history

(a) Have you ever worked at a coal mine? Yes No

If Yes, answer (b) to (g); if No, go to (h)

(b) When did you first start work in the coal mining industry?

i. Started work underground

ii. Started work aboveground

(c) How many total years have you worked in the coal mining industry?

i. Underground

ii. Aboveground

(d) How many years have you worked at the face?

(e) How many total years have you worked at your current mine?

(f) i. Do you wear a respirator at work (excluding self-rescue breathing devices)? Yes No

If Yes, answer

ii. What type (Mark all that apply)

a. Dust mask (disposable)

b. Half-face mask (other than disposable)

c. Full-face

d. Powered air–purifying hood/helmet



(g) Previous coal mine position(s)

Position Mine name

(and State/ Country if not Queensland)

Employer’s business or trading name

Employer type Start year/End year

Coal mine type and work location

Mine operator

Contractor to mines

Supplier to mines

Labour hire

Underground – face

Underground – non-face

Underground – surface

Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground

Mine operator

Contractor to mines

Supplier to mines

Labour hire




Aboveground



(h) Have you ever worked in any mine other than a coal mine? Yes No

If Yes, answer i to ii; if No, go to (i)

i. Minerals mines

a. Years underground

b. Years aboveground

ii. Quarries

a. Years

(i) Have you ever worked for more than one year in any other dusty job that may have exposed you to a respiratory hazard (e.g. dust or diesel)? Yes No

If Yes, answer i to vi

i. Years working with asbestos, vermiculite or talc

ii. Years tunnelling, drilling, sandblasting

iii. Years in road construction, jack hammering, or using masonry saw

iv. Years in foundry, pottery or abrasives manufacture

v. Years welding, cutting or grinding metals

vi. Years in other dusty job(s)

Please specify jobs (for example, agriculture, farming, textiles, forestry)

2.4 Health-related history

(a) Have you previously had a medical examination under this scheme? Yes No

If Yes, answer

(b) In what year was your last examination?

(c) Have you been admitted to a hospital or undergone surgery or an operation? Yes No



(d) Have you ever had an illness or operation that has prevented you from undertaking your normal duties for more than two weeks?

Yes No

(e) Have you ever had an injury that has prevented you from undertaking your normal duties for more than two weeks?

Yes No

(f) Are you taking any medication? Yes No

(g) Do you use hearing protection whilst in noisy areas? Yes No

EMO’s comments

2.5 Have you ever suffered from, or do you now suffer from, any of the following?

Yes No Yes No

(a) Heart disease or heart surgery

(m) Sciatica, lumbago, slipped disc

(b) Chest pain, angina or tightness in chest

(n) Fractures or dislocations

(c) High blood pressure (o) Neck injury or whiplash

(d)

Deafness, loss of hearing or ear problems

(p) Back or neck pain which has prevented you from undertaking full duties

(e) Ringing noises (tinnitus) in your ears (now or in last month)

(q) Knee problems, cartilage injury

(f) Ringing noises (tinnitus) in your ears at any time since last health assessment

(r) Shoulder, knee or any other joint injury

(g) Disease or disorder of the nervous system

(s) Hernia

(h) Episodes of numbness or weakness

(t) Arthritis or rheumatism

(i) Psychiatric illness (u) Eczema, dermatitis, skin allergy

(j) Blackouts, fits or epilepsy (v) Skin cancer

(k) RSI, tenosynovitis, over-use syndrome or wrist strain

(w) Other allergies

(l) Diabetes

EMO’s comments



2.6 Previous vaccinations and blood tests

(a) When were you last immunised against Tetanus? Year

(b) When were you last immunised against Hepatitis A? Year

(c) When were you last immunised against Hepatitis B? Year

(d) When was your last cholesterol test? Year

EMO’s comments

2.7 Coal mine worker privacy, consent and declaration

(a) Privacy statement DNRME is collecting your personal information, which forms part of your medical record, under the Coal Mining Safety and Health Regulation 2017 to identify and monitor medical conditions and improve health outcomes for current and future coal mine workers. By completing this form, you agree to the information you supply being given to medical experts for the purpose of completing your health assessments as required under the Coal Mine Workers’ Health Scheme (CMWHS). The AMA will disclose your information in Section 4 of this form to your employer. DNRME may also disclose your information for research purposes if approved by an ethics committee, or to the extent necessary to carry out an assessment (including an audit) or review. DNRME will not otherwise disclose your information unless authorised or required by law.

(b) Consent to disclose personal and medical information for auditing and review To ensure the effectiveness and quality of health assessments, DNRME may need to disclose your personal information and medical records to third parties for review and audit. These third parties may be located in Australia or overseas, and will be bound by contractural arrangements which protect your information in accordance with the Information Privacy Act 2009.

For example, DNRME may need to disclose your medical records to auditors to ensure examinations are completed correctly, such as:

to check chest x-ray images are examined in accordance with the ILO International Classification of Radiographs of Pneumoconioses

that the Standards for the Delivery of Spirometry for Coal Mine Workers are followed in performing spirometry tests

that clinical and administrative decisions are complete and accurate, including that any follow-up investigations are undertaken as per the Clinical Pathway Guidelines.

Your records will only be accessed by the relevant third party for the purpose of the review or audit, and no identifiable data will be published. The third party will not keep your records once their work is complete.



The results will be returned to DNRME, who may inform the following persons of the results:

your AMA or other referring medical practitioner, and/or

medical practitioners involved in providing services for your health assessment.

The results may only be shared with other parties, for example coal mine worker employers and worker representatives, if the results are in a de-identified format.Your personal information and medical records will not be disclosed for other purposes without your consent unless if authorised or required by law.

Your participation will ensure the CMWHS protects workers from adverse health effects of mining hazards, and help with the early detection of coal mine dust lung disease. Please tick the relevant box below to indicate your participation:

I consent I do not consent

(c) Coal miner worker’s declaration (to be witnessed by EMO)

I have considered the privacy statement and consent request, and certify to the best of my knowledge that the above information supplied by me is true and correct.

Signature

……………………………………………………

Date / /

Witness

…………………………………………………...

Date / /


Form CMSHR 1 – Health assessment form – Section 3 (EMO to complete) Version 5 – effective 1 March 2019 of 26 This form was approved by the chief inspector under section 281 of the Coal Mining Safety and Health Act 1999

Section 3 – Examining medical officer (EMO) to complete

3.1 ID Check

Has the Coal Mine Worker (the worker) supplied photo identification? Yes No

3.2 Height and weight measurement

(a) Height (cm)

(b) Weight (kg)

EMO’s comments

3.3 Vision examination

(a) Visual acuity

Uncorrected Corrected

Right Left Right Left

i. – ii. Distant 6/

6/ v. – vi. 6/ 6/

iii. – iv. Near N

N vii. – viii. N N

(b) Visual fields (by confrontation)

i. Visual fields test Normal Abnormal

(c) Colour vision (if indicated as a specific position requirement by the employer in Section 1)

i. Was an Ishihara colour vision test carried out Yes No

If Yes, answer ii. Ishihara test result Normal Abnormal

NOTE: The AMA is to recommend in Section 4.3 that an appropriate practical colour vision test is performed if an abnormal result impacts on a worker’s fitness for current/proposed position.

EMO’s comments



3.4 Hearing examination

(a) Audiogram

500 Hz 1000 Hz 1500 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz 8000 Hz

i.- viii. Left

ix. - xvi. Right

(b) Number of hours since high noise exposure

hours

(c) Audiogram result Acceptable Unacceptable

NOTE: The result is acceptable if the average hearing threshold is 40 dB or less in the better ear across 500 Hz, 1000 Hz, 1500 Hz and 2000 Hz.

NOTE: The AMA is to recommend in Section 4.3 that an appropriate practical hearing test is performed if an abnormal result impacts on a worker’s fitness for current/proposed position.

(d) Were hearing aids used for this audiogram? Yes No

(e) Auditory canals Normal Abnormal

(f) Tympanic membranes Normal Abnormal

EMO’s comments NOTE: Comment on any abnormality, including past noise exposure and tinnitus or changes from previous audiogram result or presence of ear wax that prevents examination of ear canal/tympanic membrane.

3.5 Cardiovascular function examination

(a) Blood pressure Systolic Diastolic

i. Blood pressure (Initial)

ii. Blood pressure (Repeat if necessary)

(b) Pulse

i. Rate (beats per minute)

ii. Rhythm Regular Irregular

(c) Peripheral pulses Present Absent



(d) Heart sounds Normal Abnormal

(e) Evidence of cardiac failure or oedema Yes No

(f) Varicose veins Present Absent

(g) Electrocardiogram (if indicated by some abnormality)

i. Was an ECG carried out? Yes No

If Yes, answer

ii. ECG test result Normal Abnormal

EMO’s comments

3.6 Respiratory examination

(a) Respiratory symptoms

i. Do you usually have a cough, apart from colds? Yes No

If Yes, answer ii and iii

ii. Do you usually cough on most days (e.g. 4 or more days each week) for 3 or more months during the year?

Yes No

iii. About how many years have you had this cough?

iv. Do you usually bring up phlegm from your chest, apart from colds?

Yes No

If Yes, answer v and vi

v. Do you bring up phlegm on most days (e.g. 4 or more days each week) for 3 or more months during the year?

Yes No

vi. About how many years have you had phlegm like this?

vii. In the last 12 months, have you had a wheezing or whistling in your chest at any time?

Yes No

If Yes, answer viii (Mark one) ix and x

viii. Yes, I have wheezing only when I have a cold

Yes, I have wheezing sometimes when I don’t have a cold

ix. Does the wheezing always clear when you cough? Yes No



x. When you are away from the mine on days off, is this wheezing or whistling (Mark one)

- The same

- Worse

- Better

xi. In the past 12 months, have you had an episode of asthma or an asthma attack?

Yes No

If Yes, answer xii and xiii

xii. About how old were you when you first had an attack of asthma?

xiii. Are you currently taking any medicine for your breathing? (including inhalers, aerosols, or pills)

Yes No

If Yes, answer

xiv. Mark what you are currently taking

- Inhalers

- Aerosols

- Pills

xv. Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill?

Yes No

If Yes, answer

xvi. Do you have to walk slower than people of your age on level ground because of shortness of breath?

Yes No

If Yes, answer

xvii. About how many years have you had this shortness of breath?

EMO’s comments

(b) Smoking history

i. Have you ever smoked cigarettes regularly? (Mark No if you smoked less than 100 cigarettes in your entire life; 100 cigarettes = 5 packs)

Yes No

If Yes, answer ii to ix. If No, go to x

ii. How old were you when you first started smoking?



iii. On average, for the entire time that you smoked, about how many cigarettes did you smoke per day?

Cigarettes per day

iv. About how old were you when you first started smoking cigarettes regularly?

v. Do you still smoke cigarettes? Yes No

If No, answer

vi. How old were you when you completely stopped smoking?

If Yes, answer

vii. Would you like to quit smoking now?

- Yes

- Maybe

- No

viii. During the time you were a smoker, did you ever stop smoking for six months or more?

Yes No

If Yes, answer

ix. About how long did you stop smoking altogether? NOTE: Mark the total number of years that you stopped smoking during the time you were a smoker.

x. Do you use any other inhaled tobacco or nicotine products (pipes, cigars, electronic cigarettes, e-cigarettes, etc)?

If Yes, answer

xi. Do you use them:

- Every day

- Most days NOTE: Most days means 4 or more days per week.

- Some days

EMO’s comments

(c) Chest examination

i. Chest expansion Normal Abnormal

ii. Auscultation Normal Abnormal



EMO’s comments

(d) Spirometry

i. Date of spirometry

ii. Name of spirometry practice

iii. DNRME registration number for spirometry practice

iv. Spirometry test results (attach test results)

Observed Lower Limit of Normal

(LLN)

Predicted Observed/Predicted (%)

FEV1

(litres)

i. iv. vii. x.

FVC

(litres)

ii. v. viii. xi

FEV1 /

FVC (%)

iii. vi. ix. xii

v. Spirometry test quality Acceptable

NOTE: If unacceptable, EMO to ensure spirometry test is repeated. Unacceptable

vi. Overall spirometry result Normal Abnormal NOTE: When interpreting spirometry result refer to DNRME spirometry standards and use GLI predicted values.

NOTE: If any obstruction ie FEV1/FVC <70%, or FEV1<LLN, repeat spirometry after bronchodilator.

(e) Comparative assessment (to be completed by AMA)

i. Has a respiratory function examination been conducted previously?

Yes No

ii. If Yes, has previous respiratory data been made available? Yes No

NOTE: EMO/AMA can request a copy of the coal mine worker’s previous spirometry results from the DNRME Health Surveillance Unit

If Yes, answer iii and iv

iii. Date of previous respiratory function examination



iv. Has there been a significant deterioration since the last respiratory function examination? (≥ 15% deterioration in FEV1 or in FVC)

Yes No

AMA’s comments

(f) AMA’s review of respiratory function examination

NOTE: The AMA is to arrange referral for abnormal respiratory function examination results as per the Clinical Pathway.

i. Was the coal mine worker referred for laboratory lung function test

Yes No

ii. If Yes, laboratory function test results (attach test report) Normal Abnormal

iii. If No, does the coal mine worker need to have repeat spirometry in 12 months?

Yes No

AMA’s comments

(g) Chest x-ray examination

i. Was a chest x-ray carried out? Yes No

If No, explain reason in comments below

If Yes, answer ii to iv (attach x-ray and ILO report)

ii. DNRME registration number for imaging practice

iii. Date of chest x-ray

X-ray must be first examined to the ILO classification only by a radiologist registered as a B-reader with DNRME. The image and report must then be sent to Lungscreen Australia for further reading.

iv. Date of ILO classification by Lungscreen Australia NOTE: an ILO classification completed by University of Illinois at Chicago B-readers may be used for chest x-rays taken before 1 March 2019.

v. Image quality

vi. Any classifiable parenchymal abnormalities? Yes No



If Yes, answer

vii. Profusion category

viii. Any pleural plaques present? Yes No

ix. Is costophrenic angle obliteration present? Yes No

x. Is diffuse pleural thickening present? Yes No

xi. Any other abnormalities present? Yes No

EMO’s comments

(h) AMA’s review of x-ray examination

NOTE: The AMA is to arrange referral for abnormal chest x-ray results as per the Clinical Pathway.

i. Was worker referred for high resolution CT scan? (if Yes, attach results)

Yes No

ii. Was worker referred to specialist physician? (if Yes, attach report)

Yes No

iii. Was a work-related respiratory disease diagnosed? Yes No

NOTE: If a disease is diagnosed please notify the DNRME Health Surveillance Unit at [email protected]

AMA’s comments

3.7 Musculo-skeletal function examination

(a) Lower back

i. Range of movement Normal Abnormal

ii. Posture and gait Normal Abnormal

iii. Straight leg raising Normal Abnormal

(b) Neck

i. Range of movement Normal Abnormal



(c) Joint movements

i. Upper limbs Normal Abnormal

ii. Lower limbs Normal Abnormal

iii. Reflexes Normal Abnormal

EMO’s comments

3.8 Urinalysis test and blood sugar level

(a) Urinalysis

i. Sugar Present Absent

ii. Protein/albumin Present Absent

iii. Blood Present Absent

(b) Blood test (optional)

Blood sugar level Normal Abnormal

EMO’s comments

3.9 Abdominal examination

(a) Abdominal scars Present Absent

(b) Abdominal mass Present Absent

(c) Hernia Present Absent

EMO’s comments



3.10 Skin examination

NOTE: Review coal mine worker’s responses in Section 2.5.

(a) Eczema, dermatitis or allergy Present Absent

(b) Skin Cancer or other abnormality Present Absent

3.11 Is the worker’s fitness for duty likely to be affected by any of the following?

(a) Dietary habits Yes No

(b) Exercise routine Yes No

(c) Stress level Yes No

(d) Alcohol consumption Yes No

(e) Drugs or medication not prescribed by a doctor Yes No

3.12 Is there any reason why the worker may be not fit for duty in relation to work?

(a) As an operator of (or working around) heavy vehicles Yes No

(b) Underground (including use of self-rescue breathing devices and escape) Yes No

(c) Shift work Yes No

(d) Performing heavy manual handling Yes No

(e) In wet or muddy conditions Yes No

(f) In dusty conditions Yes No

(g) At height or on ladders Yes No

(h) In confined spaces Yes No

(i) While wearing safety footwear or other personal protective equipment such as ear plugs, glasses and respirators Yes No

(j) Another capacity – define

Yes No



EMO’s comments

3.13 EMO details (if different to AMA)

(a) Date of examination

(b) Name

(c) Practice name

(d) DNRME registration number for EMO

(e) Address

(f) Telephone number

(g) Email address

Practice stamp

………..…………………………………

EMO Signature

Date / /


Family name First name Date of birth Employer

Form CMSHR 1 – Health assessment form – Section 4 (AMA to complete) Version 5 – effective 1 March 2019 of 26 This form was approved by the chief inspector under section 281 of the Coal Mining Safety and Health Act 1999

Section 4 – Appointed Medical Adviser (AMA) to complete Health assessment report

4.1 Coal Mine Worker (worker) details

(a) Family name

(b) First name

(c) Middle name

(d) Date of birth

(e) Employer

(f) Name of mine

(g) Worker’s proposed/current position

(h) Date of examination by EMO

4.2 Respiratory function and chest x-ray summary

(a) Date of the worker’s previous respiratory function examination if known/applicable

No previous

examination

Unknown

(b) The worker has had a comparative assessment of their respiratory

function Yes No

If No

i. Was this the first or baseline assessment? Yes No

ii. Was a previous health assessment available for comparison? Yes No

(c) Date of the worker’s most recent chest x-ray:

(d) Date of ILO classification by Lungscreen Australia NOTE: an ILO classification completed by University of Illinois at Chicago B-readers can be used for chest X-rays taken before 1 March 2019.

(e) I have reviewed the results of the worker whose name appears in section 4.1a (above), and the worker (tick all boxes that apply):

i. Displays indications of adverse health effects that may be attributed

to exposure to a causative agent at the mine Yes No




ii.

1. has been diagnosed with the

following prescribed disease(s) by a respiratory physician following the Clinical Pathway:

chronic obstructive pulmonary disease

coal workers’ pneumoconiosis

silicosis

2. has been diagnosed with legionellosis

3. has not been diagnosed with

one of these diseases

(f) I have advised the worker to seek further advice as to the treatment/

management of their medical condition from their treating medical practitioner

Yes No

4.3 Fitness for duty

(a) Recommended date of next full periodic health assessment

(b) The worker requires a subsequent assessment (review) before the next

periodic health assessment NOTE: Subsequent assessment must be undertaken where practical vision or hearing test is recommended, or where repeat spirometry is necessary prior to next periodic health assessment, for AMA to consider test results.

Yes No

If Yes, answer

(c) Date of subsequent assessment

(d) Matter(s) to be assessed at subsequent assessment

(e) As at the date of this examination, the worker:

Is suitable for and has no condition which precludes participation in mines rescue

See Mines Rescue Medical Guidelines

For Queensland Mines Rescue Service personnel / applicants only.

Is fit to undertake any position

Is fit to undertake the proposed / current position

Is fit to undertake the proposed / current position subject to the following restriction(s) (if necessary, outline a management program)

Is not fit to undertake the proposed / current position because of the following restriction(s):

https://www.dnrm.qld.gov.au/__data/assets/pdf_file/0015/241017/QMRS-guideline.pdf




The duration of the restriction is:

4.4 Declaration

(a) As AMA, I have explained the outcome of the health assessment to the worker

Yes No

(b) As AMA, I have provided a copy of this report to the worker Yes No

(c) The worker has given written consent for the AMA to provide an

explanation of this report to the employer with the worker present Yes No

Worker’s declaration — I have been advised of the outcome of this health assessment

(Practical constraints prevent this from being a compulsory item)

Worker’s signature ……………………………………………………

Date / /

4.5 AMA details

(a) Date of examination

(b) Name

(c) Practice name

(d) DNRME registration number for AMA

(e) Address

(f) Telephone number

(g) Email address

Practice stamp

………..…………………………………

AMA Signature

Date / /

cmshr 1 health assessment form · department of natural resources, mines and energy form cmshr 1...

Documents