USECHH 4
Occupational Safety & Health Act 1994(Act 514)
Use and Standard of Exposure of Chemicals Hazardous to Health Regulations 2000
SUMMARY REPORT FOR MEDICAL SURVEILLANCE
Name of Workplace……………………………………………………………………………………………………………………………………………………
Address of Workplace………………………………………………………………………………………………………………………………………………..
Company revenue/annual income in RM…………………………………………………………………………………………………..
Work unit where workers are in (please √): Production Maintainence Chemical/Heavy Metals
Laboratories Pesticides Others(to specify):…………………………………………………..
Range Date
Workplace exposure monitoring
Personal exposure monitoring
Control measure monitoring
Individual chemical……………………………………………………………………………………………………………………………………
(Use on USECHH 4 form for one chemical only!)
Chemical listed under which schedule under USECHH 2000 Regulations:…………………………………………………
Date of CHRA conducted(please put not done if CHRA not done)……………………………………………………………..
Total number of workers in that workplace……………………………………………………………………………………………..
Total number of exposed workers………………………………………………………………………………………………………….
Type of test performed ( please mention specifically each lab investigation done)
……………………………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………………..
EXAMINATION(S) RESULTS
Clinical Features & Biological Other test (to specify)
Monitoring Blood/ Spirometry/Urine etc
No. of workers examined
No of workers with normal results
No of workers with abnormal
results (Occupational caused)
No of workers with abnormal
results (Non-occupational caused)
No of workers recommended for
removal
Name of Laboratory:………………………………………………………………………………………………………………………………………………
I hereby declare that all particulars given in this report are accurate to the best of my knowledge
Name of Occupational Health Doctor:……………………………………………………………………………………………………………………..
OHD registration no:……………………………………………………………………………………………………………………………………………..
Name of practice and address: ………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………
Duration/experience as medical practitioner (in years) ………………………………………………………………………………………….
Tel no: ....................................... HP no: …………………………………………… Fax no: ……………………………………………………..
Valid email address…………………………………………………………………………
Date: Signature:
Submit this
Submit thisform
formwithin
within3030days
daysofof completion
completion of medical
of medical surveillance
surveillance toDirector
to the the Director General,
General, Department
Department of of
OccupationalSafety
Occupational Safetyand
andHealth,Level
Health, Level
1, 2,
3, 43,and
& 4,5,Block
BlockD3,
D4,Parcel D, 62530
Complex Putrajaya.
D, 62530 Download
Putrajaya. this
Download form
this atat
form
http://www.dosh.gov.my .Please ensure all items in the form are completed. Incomplete forms will be returned.
http://www.dosh.gov.my .Please ensure all items in the form are completed. Incomplete forms will be returned.
