Professional Documents
Culture Documents
Page
1 Introduction ................................................................................................................................... 2
2 Principles and Procedure .............................................................................................................. 2
3 Supporting Clauses..................................................................................................................... 66
4 Authorisation ........................................................................................................................... 1111
5 Revisions ................................................................................................................................ 1111
6 Development team .................................................................................................................. 1111
Annexes
Annex A Medical Surveillance Matrix ........................................................................................ 1212
Annex B Medical Surveillance and Control of Eskom Employees ............................................ 1515
Annex C Risk Exposure Medical Examination .......................................................................... 2222
Annex D Focused Medical Examinations .................................................................................. 2424
Annex E Shift Work Questionnaire ............................................................................................ 2525
Annex F Hazard Risk Exposure Questionnaire ......................................................................... 2626
Annex G Fitness to Drive/Critical Task Questionaire ................................................................ 2727
1 Introduction
Medical Surveillance is based on the occupational risk exposure of employees. It is a statutory
requirement according to the Occupational Health and Safety Act no 85 of 1993 and forms an essential
component of an Occupational Health and Safety programme. The Medical Surveillance is a planned
programme of periodic medical examinations which may include clinical examination, biological
monitoring and/or medical tests of employees by an Occupational Health Nurse Practitioner or, in
prescribed cases, by an Occupational Medical Practitioner.
i. Whether or not the prospective candidate or employee is physically/mentally fit, and able to
perform, the inherent requirements of the prospective or current job without any ill effects.
ii. Whether or not he/she is able to perform the work, but with reduced efficiency or
effectiveness.
iii. Whether he/she is able to perform the work, although this may adversely affect the medical
condition.
iv. Whether he/she is able to perform the work, but not without unacceptable risk to the health
and safety of himself/herself, other workers or the community.
vi. Whether he/she is disabled and voluntarily declares in terms of the Employment Equity Act as
they present themselves for examinations.
c. To provide a baseline health status against which future changes can be measured.
e. To ensure early identification of chronic medical conditions, which need continuous monitoring and
management.
2.1.1 The principle of conducting a General Occupational Medical Examination (GOME) is to detect a
disease at an early sub-clinical or pre-symptomatic stage, in order to take action to reverse these
effects, or to slow progression of the disease, e.g. Audiometric testing is applicable to employees
exposed to noise.
2.1.3 The frequency and the nature of the evaluation shall be based on the following:
a. The health hazards to which an individual is exposed and the length of time.
2.1.4 The Medical Surveillance Programme shall be co-ordinated by the relevant Occupational Health
Nurse Practitioner. For the programme to be effective and sustainable, the following elements are
essential:
The OHP, Occupational Hygienist, Risk Practitioner and line manager should:
a. Conduct a health risk assessment to determine the potential exposure to, hazards, hazardous
chemical substances and environmental stressors e.g. fly ash, asbestos and noise.
b. Identify the target organ that is exposed for appropriate medical screening e.g. hearing test for
noise.
c. Select the appropriate tests and specify testing schedule as well as action criteria e.g. 6/12 months
hearing test done on employees exposed to noise over 105 decibels.
d. Ensure biological monitoring is done on all employees exposed to hazardous chemical substances
such as toulene, mercury, benzene, PCP, and ionizing radiation.
e. Ensure that standardised testing methods and machines are used to ensure consistency.
2.1.5 When assessing fitness for duty, one of the following recommendations shall be made:
2.1.6 The relevant line manager will be accountable for medical costs incurred as necessary, should
the employee need further tests to determine fitness for duty. The OHP should discuss proposed
referral with the line manager and Eskom Medical Practitioner before costs are incurred
2.1.7 A completed Man job/task specification form shall be completed by the line manager prior to a
medical evaluation with the most up to date risk profile.
2.1.8 A Hazard Risk Exposure Questionnaire (Annex G) shall be completed by line manager prior to
a medical evaluation.
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2.1.9 An individual OREP shall be compiled for each employee, as informed by the completed "man
job/task specification form" prior the medical evaluation by the OHP.
2.1.10 The OHP shall conduct relevant examination tests as indicated by the individual OREP. The
findings shall be recorded on the Medical Surveillance form (Annex B), communicated to the employee
and the line manager with employees informed consent.
b. When being transferred to a new risk area complete Section A of Medical Surveillance Form.
c. After a period of prolonged sick leave of > 30days. complete Section B of the Medical Surveillance
form.
d. When the employee leaves the organization by resignation, ill-health retirement and pension
complete Section C of the Medical Surveillance Form.
e. In the event that disabilities are picked up during the medical examination, as stipulated in the
EE Act. of 1998, employees are expected to voluntarily complete a declaration form which must be
endorsed by an Eskom Medical Practitioner. Some employees may choose not to declare.
Recommendations and results of the medical examination shall be discussed with the employee, and
with the line manager only with the full informed consent of the employee.
The OHP shall ensure that all data is captured on SAP EH&S.
2.2.1.1 The following documentation is required from HR Shared services and relevant line manager
prior to conducting a general occupational medical examination for a Pre-employment Health
Screening Medical, exit and, transfer medical evaluations.
a. Request shall be sent through the OHNP fourteen (14) days before the examination to allow for
proper planning
b. Man job/task specification form of the relevant medical examination shall be completed fully by
line manager.
a. Line Manager in collaboration with the OHP shall schedule employees according to the risk
profiles, e.g. noise, ionising radiation, dust, HCS, sewerage and drivers.
b. A completed man job/task specification form shall be given to the employee prior to the medical
examination
Note: Previous exposures to asbestos, silica and cadmium need continual monitoring even if persons are no longer
exposed in current occupations.
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a. The exit health screening medical shall be conducted on employees transferring to other Eskom
business areas or going on retirement and separation. HR SSU shall request an exit medical
screening with the OHNP fourteen (14) working days after he/she has received the employees
resignation letter or GA2 if it is a transfer.
b. The OHP shall discuss the recommendations and results with the employee and the line manager
with the employees informed consent.
c. The OHP shall give the employee a copy of the medical results including the baseline hearing test
on request.
d. In the event that the exit medical screening results are abnormal, indicate a suspected
occupational exposure related disease; the employee shall be referred for confirmatory diagnosis
after consulting with the Eskom Occupational Medical Practitioner. Follow-up shall be ensured so
as to report the confirmed disease to COIDA.
The following people must be notified after obtaining confirmation to start Incident investigation:
a. JJACCOL
c. Urine testing
e. Abdominal Circumference
f. Vision test
g. Lung Function
h. Audiometric test
The purpose of this questionnaire is to obtain information regarding health risk exposure from the
prospective employee. It is intended to complement the information obtained from the completed man
job/task specification form and not to replace it. It shall be completed prior to all medical evaluations.
The purpose of this questionnaire is to ask specific and detailed questions which pertain to driving and
critical tasks. This questionnaire shall be completed prior all medical examinations related to assessing
fitness to drive and performance of critical tasks.
The purpose of this questionnaire is to identify the early problems associated with shift work. It shall be
completed by all shift workers prior to periodic medical screening.
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This matrix is a summary of the different types of medical evaluation, frequency, target organs and
medical tests such as biological monitoring to be done. The purpose of the matrix is to serve as a quick
reference. It should be used in conjunction with the medical surveillance protocols.
2.3.1 The OHP shall ensure that all data is captured on SAP EH&S.
2.3.2 The relevant OHP shall be responsible for the maintenance and administration of all applicable
medical records as determined by the OHS Act no 85 of 1993 and keep them for 50 (fifty) years in a
fire-proof cabinet or archive them where necessary.
2.3.3 If employee transfers to another BU, the relevant OHP shall ensure that the employees medical
files are forwarded to the next applicable OHP. An audit trail of the records shall be kept.
2.3.4 All medical records shall be kept in accordance with accepted medico-legal practice, as well as
Eskom requirements. They shall be kept in strict confidence. They shall only be discussed with other
members of the medical team on a need to know basis and, with the written informed consent of the
employee.
2.3.5 Medical records may be made available to other members of the medical team (any
professional registered with the Health Professions Council of South Africa, or the South African
Nursing Council), subject to the following requirements:
2.3.6 Management shall only be provided with information on the following reasons:
b. Where it is necessary for management to know about a reportable Occupational Disease or Injury
and an incident investigation is to be instituted.
c. Where it is necessary for management to institute additional control measures in terms of hazard
or environmental stressors control.
In all cases, written informed consent shall be obtained from the employee.
3 Supporting Clauses
Index of Supporting Clauses
3.1 Scope
3.1.1 Purpose
The purpose of this document is to prescribe the procedure to be observed for the medical surveillance
and control of Eskom employees, bursars, learners, apprentices and contractors so as to establish and
maintain their physical and psychological capacity to efficiently discharge their duties and training.
3.1.2 Applicability
This procedure shall be applicable throughout Eskom Holdings Limited and its divisions.
The following documents contain provisions that, through reference in the text, constitute requirements
of this procedure. At the time of publication, the editions indicated were valid. All controlled documents
are subject to revision, and parties to agreements based on this procedure are encouraged to
investigate the possibility of applying the most recent edition of the documents listed below.
Information on currently valid national and international standards and specifications can be obtained
from the Information Centre and Eskom Documentation Centre at Megawatt Park.
3.2.1 Informative
3.2.2 Normative
3.3 Definitions
3.3.1 Biological Monitoring: a planned programme of periodic collection and analysis of body fluids,
tissues, excreta, or exhaled air in order to detect and quantify the exposure to, or absorption of any
substance or organism by exposed persons.
3.3.2 Baseline Audiometry Screening: screening for hearing using equipment which meets
Eskoms prescribed standard, but conducted under conditions which comply with SANS 10 083
requirements in terms of mobile equipment requirements. The baseline report shall be used as
reference in the next hearing screenings that follow the baseline.
3.3.3 Medical Surveillance: is a planned programme of risk based periodic examinations (which
may include clinical examinations, biological monitoring or medical tests) of employees by an
occupational health nurse or in prescribed cases, by an occupational medicine practitioner. The results
from this programme act as an important indication of the adequacy of worksite health and safety
control measures.
3.3.4 Man-job/task specification form: A document in which critical performance areas (work
activities) of a particular job and the hazards to which the employee is exposed are identified. These
specifications will dictate the physical and mental inherent requirements necessary to perform the job.
3.3.5 Periodic Health Screening: a medical examination and/or tests performed on a regular basis
throughout an employees work life cycle in order to monitor their health status in relation to the
specific health and safety hazards to which they are exposed.
3.3.7 Occupational Health: means the anticipation, recognition, evaluation and control of conditions
arising from the workplace, which may cause illness or adverse effects to persons.
3.3.8 Occupational Risk Exposure Profile: occupational risks that an employee is exposed to
and the relevant medical examinations and their frequency that must be conducted on the employee.
3.3.10 SAP EHS: the environment health and safety module of SAP .
3.4 Abbreviations
a. The Health and Wellness Manager will be responsible for updating this procedure.
b. The Divisional HR Managers will be responsible for implementing the conditions in accordance
with this procedure.
b. Conduct medical surveillance in terms of the applicable statutory and ethical requirements.
c. Ensure that all medical records are captured into SAP EH&S and kept in a fireproof cabinet for
fifty years (50), under lock and key. Records shall be kept in confidence.
The relevant line manager shall, in consultation with the relevant OHP, safety risk practitioner,
occupational hygienist and occupational health and safety representatives with any other applicable
functionaries:
System audits will be conducted and divisional HR Managers and Risk Managers will be informed of
the corrective actions to be taken.
4 Authorisation
This document has been seen and accepted by:
Name Designation
PJ Maroga Chief Executive
B Nqwababa Finance Director
ME Letlape Managing Director (Human Resources Division)
EN Matya Managing Director (Generation & Generation Primary Energy Divisions)
E Johnson Managing Director (Systems Operations and Planning Division)
MM Ntsokolo Managing Director (Transmission Division)
JA Dladla Managing Director (Office of the Chief Executive)
Dr SJ Lennon Managing Director (Corporate Services Division)
BA Dames Managing Director (Enterprises Division)
A Noah Managing Director (Distribution Division)
5 Revisions
Date Rev. Remarks
6 Development team
The following functionaries have also provided input and have assisted with the development of this
procedure:
a. Dr Mike Simon
b. Sr Belina Ramogase
c. Dr Andre Botha
d. Dick Huyser
e. Sr Mary Marrie
f. Sr Thabitha Mashile
g. Sr Joey Mankge
h. Sr Christina Moleko
i. Sr Lallie Fourie
j. Sr Gele Mphasi
k. Sr Raelene Bloy
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Annex A
(informative)
Frequency of
Situation Type of Medical Surveillance
surveillance
Pre-employment. GOME Pre-employment
At transfer GOME Prior to transfer
At exit from the organization. GOME Prior to leaving
After prolonged sick leave (> 30 days per GOME Post illness
annum, consecutive or intermittent).
Annex A
(continued)
Frequency of
Situation Type of Medical Surveillance
surveillance
Cadmium exposed workers Urine beta-2-microglobu-lin 12 monthly
levels
Urine cadmium levels
Pulmonary function testing
Shift workers Shift Worker Questionnaire 12 monthly
Heavy Manual workers > 50 years Physical Ability 12 monthly
Assessment
Heavy Manual Workers < 50 Physical Ability Evaluation 24 monthly
Food handlers Hygiene education, Check 12 monthly
history of typhoid, colostomy,
respiratory disease.
Check skin.
Live Line workers Critical Task Questionnaire 12 monthly
Vibration exposed workers (whole-body) Ask re.: low back pain 24 monthly
Hand-arm Ask re.: hand or arm 24 monthly
pain/parasthesae
Vibration sense
Two point discrimination
Public Drivers permit Fitness to drive/critical task 12 monthly
(Code C1, C, EC, & EC1) (Medical questionnaire
Doctors only) * Requirements of Road Traffic
Special Drivers e.g. forklift/crane Act and SASOM Guidelines
Dx Critical Tasks * Risk exposure specific periodic
health screening
* These requirements apply to
drivers and critical task workers
Non-Vocational drivers Fitness to drive/critical task 36 monthly
questionnaire
Risk exposure specific periodic
health screening
Ergonomic exposure Specific questions related to 36 monthly
upper limb pain. If present try to
make a diagnosis
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Annex A
(concluded)
Frequency of
Situation Type of Medical Surveillance
surveillance
Asbestos exposed workers Respiratory system history and 24 monthly
examination
Pulmonary Function Tests
Chest X-Ray
Silica/dust exposed workers Ask re: cough, shortness of 24 monthly
breath.
Examine respiratory system
Pulmonary Function tests
36 monthly
Chest X-Ray
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Annex B
(informative)
UNIQUE NO: ..
occupational risk exposure profile (OREP) of all applicants and Eskom employees in accordance with:
Occupational Health and Safety Act and Regulations no. 85, of 1993
32-282 Procedure for Medical Surveillance
32-81 Procedure for Protection of employees during pregnancy and after birth of a child
32-73 Procedure for Primary health Care
SCSASACA2 - Medical Surveillance Standard (under review)
LD-1077: Requirements for the Medical and Psychological Surveillance and Control
ESKADAAS4: Medical Surveillance and Control of Nuclear Installation Personnel (under review)
KSA-055, Rev 1: Requirements for the Medical and Psychological Surveillance and Control
Programme
KAA-591: Medical and Psychological Surveillance and Control of Radiation Workers and Licensed
Operators
OBJECTIVES:
Medical Surveillance and Control of Radiation workers and Licensed operators
to evaluate and ensure the physical and psychological capacity of an applicant to work efficiently in his/her
intended occupation;
the promotion and securing of the health and safety of employees through the early detection of disease;
to ensure the safe performance of duties and execution of work processes through timeous detection of
risks to safety and health;
to comply with statutory requirements;
to establish a baseline of the employees health status and to monitor health throughout Eskom work-life.
MEDICAL EXAMINERS:
all pre-placement and periodic medical examinations are to be conducted by authorised Eskom
Occupational Health Practitioners (Occupational Health Nursing and Medicine Practitioners);
Where Eskom Occupational Health Practitioners are not available, pre-placement medical examinations
may be conducted by an external qualified Occupational Health Practitioner, if not available then by a
registered General Practitioner. Such medical examinations must be endorsed by an Eskom Occupational
SCSASACA2 - Medical Surveillance Standard
may only be conducted by a National Nuclear Regulator approved appointed medical practitioner;
32-282 Medical Surveillance Procedure
Pre-placement and periodic medical examinations of pilots to be conducted by a Civil Aviation Authority
registered Senior Medical Aviation Examiner.
INSTRUCTIONS:
the assessment of medical fitness is the responsibility of the Occupational Health Practitioner and is made
as a result of an appropriate medical evaluation, knowledge of the content and health risks of the
occupation, safety risk of the work process and with due regard to legislated requirements;
an OREP of each examinee is to be compiled at pre-placement, transfer and at periodic medical
evaluations;
the OREP of an employee shall determine the frequency and nature of the medical examination;
the periodic medical screening shall be dictated by the inherent requirements of the job and legislated
requirements and should include a clinical and occupational history and appropriate examination and tests;
business units are responsible for all costs of pre-placement and periodic medical examinations and related
special investigations;
the pre-placement and periodic medical examination form with attached special investigation reports and
the OREP of an employee are medico-legal documents which are to be retained by the employer for
50 (fifty) years from date of termination of employment.
copies of medical report shall be released to employees upon written request.
Annex B
(continued)
DECLARATION
Date (DD-MM-CCYY)
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Annex B
(continued)
A. PRE-PLACEMENT/TRANSFER MEDICAL EXAMINATION Date
1. Full Names, incl. Surname 2. Telephone Numbers 3. FREQUENCY CATEGORY BASED ON OREP (Page 5)
A B C D
4. Home Address ( ) (Work) 5. Occupation 6. Business Unit 7. Section
Postal Code
( ) (Home)
8. Date of birth 9. Age 10. Sex 11. Designation 12. ID Number 13. Unique No.
(DD-MM-CCYY)
16. Medical History: If YES please provide complete details below (if space is insufficient, add supplementary notes on separate sheet)
(N = No, Y = Yes)
Have you ever had, or do you Have you ever had, or do you now Have you ever had, or do you now
N Y N Y N Y
now have: have: have:
1. Freq. or severe headache/ 12. Tuberculosis 23. Malignant tumours or cancer
migraine
2. Fainting attacks or dizziness 13. Stomach, liver/intestinal trouble 24. Skin disease (psoriasis/eczema)
3. Head injury/concussion/ 14. Heart trouble/high blood pressure 25. Sleep disorders
unconsciousness
4. Blackouts/epilepsy/fits 15. Shortness of breath, chest pain or 26. Varicose veins causing problems
palpitations
5. Depression/anxiety or any other 16. Sinus problems 27. Any symptoms which frequently
nervous or psychological prevent you from going to work for a
problems day or two or longer
6. Eye or vision trouble (except 17. Wrist, elbow, shoulder problems 28. Hernias
glasses)
7. Spectacles or contact lenses 18. Back/neck trouble, chronic 29. Any other illness or injury
backache, a pinched nerve in the
spine.
8. A discharge from either ear 19. Foot, ankle, knee or hip trouble Are you now or have you ever been: N Y
9. Hearing disorders or deafness 20. Arthritis or any joint problems. 30. Treated for alcohol/drug addiction
10. Allergies: Respiratory/Skin/ 21. Kidney stone or infections 31. A smoker (cigs. or pipe) if yes: How
Med. many per day: How long:
11. Asthma/lung disease/chronic 22. Diabetes, Thyroid, Blood disorders 32. Admitted to hospital (for any reason)
cough
33. Exercise: Time/frequency 34. Alcohol/drug consumption: Units per time
35. Hobbies: Type: 36. Medicine: Please indicate what medicines you are currently using or
have used at any time in the last 2 years (prescription and non-prescription)
37. (Females only) Date of last menstrual period / Last pregnancy:
43. Medical treatment within the last three (3) years, which required sick leave >7 days of hospitalisation
Date Name of Medical Practitioner, Specialist, etc. Diagnosis/treatment
REMARKS (To be completed by Medical Examiner, Comment in full on all items marked YES)
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Annex B
(continued)
43. (cont.)
PRE-PLACEMENT/TRANSFER MEDICAL EXAMINATION
39. Mass 40. Height 41. Pulse 42. Blood 43. Urina-
Leucocyte
Not done
(kg) (cm) rate/min Pressure. lysis
Billirubin
Glucose
Ketones
Nitrates
Protein
Mm/hg
Urobil
Blood
pH
Lying Standing
Annex B
(continued)
OCCUPATIONAL RISK EXPOSURE PROFILE
Name: A. Annual Food handlers B. 2-yearly Tech/other C. 3-yearly Admin D. More frequently
BU: Examiner: Nuclear Live-line workers Heavy manual <50 Driver IV (Compromised health)
Unique Nr.: Pilots Tech-chemical SHE & S
Department Date: Shiftworkers Heavy manual >50
Occupation: Heatworkers years,Drivers I,ll,lll Critical task
Wellness Quest
CoBreathalyser
Vibration sense
Resp.hist/exam
Ergonom. Eval.
Shiftwork Ques
Two pt. discrim
Crit Task/Driv Q
Skin hist/ exam
Beta 2 Microblob
Psycho-Eval
Lung Function
Audiometry
Cholinesterase
Frequency
Haz Quest
Full Exam
Compromised
Basic Exam
Exposure
Exposure
Exposure
Exposure
Exposure
GAMMA GT
ALK PHOS
Neuro
Vision
Cadmium
CXR
PCA
FBC
Mercury
Bilirubin
Normal
At Risk
S.ALT
Lead
AST
Physical
Env.
Noise 85 dB 12
105 dB
105 dB 6
Vibration 24
Thermal: Hot 12
Cold 24
Erg. Stress 36
Elect.Contact
Illumination 36
Phys. Work 24
Heavy >50 12
manual <50 24
Critical Task 24
Office 36
Plant/wshop
Field 24
Transport 24
Radiation
Env.
Ionising 5 mSc 24
>5 mSv 12
Non-ionising 24
EMF
U/V 24
Airborne
Env.
Asbestos 24
Silica 24
Coal Dust 12
Gases/ Vapours 12
(CO2, SF6)
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Annex B
(continued)
Chemical
Env.
Metals: Lead 6/
12
Mercury 12
Cadmium 12
Weld & 12
solder fumes
Solvents, oils 12
& greases
PCB 12
Pesticides 12
Diesel/petrol 12
Psycho-
Social
Mental 12
Stress
Shift work 12
Other
Medical Surveillance Unique Identifier 32-282
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Annex B (concluded)
Blood
Urine
Exp. Profile
Months
BE - Basic Exam
Driver/
Quest.
Basic
CXR
LFT
AM
PE
VF
PCA
PE - Psychological Exam
TToxicol
LFTs
FBC
AM - Audiometry
Annex C
(informative)
Risk Exposure Medical Examination
B. NOTE: Select appropriate examination/tests. RISK EXPOSURE MEDICAL EXAMINATION
C. Exit Examination
based on hazard profile of individual
1. Brief details of any illness, accident & treatment since last exam. T/F to BU OREP Category
2. Systematic history to be probed at each periodic medical exam.
Medical 3. Hobbies, smoking, alcohol, medication, diet and exercise habits.
4. Any new Allergies
Occ. Age OREP Occ. Age OREP Occ. Age OREP Occ. Age OREP
History Resigned Retirement
Exit Ill
Discharged Normal Early
health
Current Medical / Surgical / Psychosocial history
Histo
ry
Annex C
(concluded)
FEV %
Chest X-Ray NAD/ABN
CO CO NAD/ABN/ Not done
PCA PCA NAD/ABN/ Not done
FBC NAD/ABN/ Not done
S. ALT NAD/ABN/ Not done
Blood
C
4. D
5. E
See page 4 for explanation
O.H. Practitioner Name & Signature
Medical Centre
Date
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Annex D
(informative)
Focused Medical Examinations
FOCUSED MEDICAL EXAMINATIONS ADDITIONAL NOTES
Annex E
(informative)
QUESTIONS YES NO
If you answered yes to any of the questions above, please provide any details in the space below.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
The above information will be treated in the strictest confidence by Eskom Health and Wellness Services
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Annex F
(Informative)
Tick below
EXPOSURES QUESTION YES NO
1. Organic Do you work with or near electrical cleaning substances
solvents degreasing agents, thinners, petrol, pesticide or herbicide sprays,
oil based paints, varnishes or glues ?
Please list the substances you are exposed
to.
7. Shift Work Do you perform regular shift work or abnormal overtime work?
Annex G
(informative)
YES NO
1. Epileptic seizure?
2. Loss of consciousness or blackout?
3. Falling asleep while driving or similar activity?
4. Any disease or condition of the brain or nervous system?
5. Attacks of dizziness or vertigo (a spinning sensation)?
6. Attack(s) of temporary, partial or complete blindness?
7. A heart attack, angina or disturbance of the pulse rate or rhythm?
8. Any other heart disease?
9. High blood pressure?
If on treatment, please list your medication plus any side effects you may be
experiencing.
Name of medication and side effects
_________________________________________________________
_________________________________________________________
10. Diabetes?
If yes, (Circle the correct answer)
Insulin?
Tablets?
Both?
Annex G
(concluded)
13. Are you taking an anti-depressant, tranquillisers, and tablets for stress or nerves or
any other medication that could impair your response or driving ability?
If so, please list the names
13.1 _________________________________________________________
13.2 _________________________________________________________
13.3 _________________________________________________________
If the answer was yes to any of the above, please provide full details in the space below.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________
DECLARATION: I certify that the above information is, to the best of my knowledge, a true and accurate reflection.