Hazardous substance health monitoring report
Complete this form if an employee is exposed to a specific hazardous substance which may present a health risk to them.
Important: Please download this PDF to your computer. You can fill it in using Adobe Reader as it may not save if you attempt to fill it in using your web browser.
What it contains
The employer must complete section 2 of the form, and supply it to the registered medical practitioner before health monitoring is provided.
The registered medical practitioner will:
- assess the employee for adverse effects
- assess the employee for adverse effects
- certify the employee's fitness to work with the hazardous substances
Employers must submit the health monitoring report to WorkSafe Victoria if the registered medical practitioner’s opinion is that the employee must not be exposed to the hazardous substance for a specified period of time.
Former engineered stone licence holders
Former engineered stone licence holders who have an employee who:
- is required to have health monitoring under regulation 169, and
- was employed by them immediately before 1 July 2024, and
- was previously required to have health monitoring under the supervision of a specialist occupational and environmental physician, or specialist respiratory and sleep medicine physician
must continue to ensure the health monitoring is conducted under the supervision of one of these specialists.
Employers who held an engineered stone licence immediately before 1 July 2024 must submit health monitoring reports to WorkSafe Victoria within 30 days of receiving the report.
The submitted health monitoring report is for an employee who:
- was required to have health monitoring carried out before 1 July, and
- is required to have health monitoring under regulation 169 after 1 July 2024.
Where required, completed health monitoring reports and any supporting recommendations should be submitted to WorkSafe Victoria by email: occupationalhealth @ worksafe.vic.gov.au.