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Health Surveillance and Monitoring Procedure

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Section 1 - Purpose

(1) The purpose of this Procedure is to:

  1. prevent or detect, at an early stage, adverse health effects resulting from use of hazardous substances or from other exposures in the workplace;
  2. ensure compliance with the duty to provide health monitoring defined by the Work Health and Safety Regulation 2017; and
  3. outline the procedure for health surveillance at Charles Sturt University (the University).


(2) This document applies to all Faculties, Divisions, Offices and organisational units of the University and its controlled entities.

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Section 2 - Glossary

(3) For the purpose of this Procedure:

  1. a Competent Person – means a person who has acquired through training, qualifications or experience the knowledge and skills required to undertake the task;
  2. Health Surveillance – is the systematic monitoring of ‘at risk’ workers for any adverse effects of work on their health as it relates to their duties. It is delivered through medical assessment and biological monitoring (e.g. audiometric testing and spirometry (lung function) testing); and
  3. Supervisor – means workers with direct supervisory responsibility for other workers within the workplace (a Supervisor may also be member of Senior Management) and who are responsible for recruitment and induction processes as well as provision of other information or instruction relating to staff in their workplace.
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Section 3 - Policy

(4) Refer to the Work Health and Safety Policy.

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Section 4 - Procedures

Part A - Responsibilities

Head of School/Head of Area

(5) The Head of School/Head of Area is responsible for ensuring that the Implementing Periodic Health Surveillance section of Part B – Health Surveillance and Monitoring are carried out. This may be delegated to a supervisor if the health surveillance and monitoring relates to a specific unit or team.


(6) In addition to worker responsibilities, supervisors are responsible for the following sections of Part B – Health Surveillance and Monitoring:

  1. implementing periodic health surveillance clauses, as directed by the Head of School/Head of Area; and
  2. incident reporting.

Manager, Health Safety and Wellbeing

(7) The Manager, Health Safety and Wellbeing is responsible for:

  1. the Documentation section of Part B – Health Surveillance and Monitoring; and
  2. providing advice on this Procedure to supervisors and Head of School/Head of Area.


(8) Workers are responsible for:

  1. participating in health surveillance where it is required;
  2. following safe working procedures as directed by the supervisor; and
  3. using appropriate Personal Protective Equipment (PPE) and safety systems.

Part B - Health Surveillance and Monitoring

(9) The University's health surveillance program is part of a range of measures to ensure the ongoing health, safety and wellbeing of workers.

(10) The health surveillance program contributes to:

  1. the prevention and detection at an early stage of any adverse health effects from exposure;
  2. assessing whether any absorbed dose of the hazardous material is acceptable compared to established occupational exposure standards;
  3. assisting in the evaluation of risk control measures;
  4. indicating biological effects requiring cessation or reduction of exposure; and
  5. general awareness of the adverse effects of exposure to hazardous materials and processes.

Implementing Periodic Health Surveillance

(11) The School/Area must provide health surveillance for workers when:

  1. a risk assessment identifies that it is required;
  2. they are carrying out ongoing work with the hazardous substances listed in Appendix A – Hazardous Substances Requiring Mandatory Health Surveillance, if there is a significant risk to the worker’s health because of exposure to these hazardous chemicals; and/or
  1. a viable health surveillance technique is available for hazardous substances not listed in Appendix A – Hazardous Substances Requiring Mandatory Health Surveillance.

(12) Ensure arrangements for health surveillance are made prior to commencement of the work.

(13) Select a suitable medical practitioner or occupational hygienist (in consultation with workers).

(14) Provide the registered medical practitioner or occupational hygienist with access to the Register/Inventory of Hazardous Substances and any relevant risk assessment records.

(15) Provide School/Area resources for health surveillance, which may include worker’s medical fees, pathology tests, traveling expenses and time away from work.

(16) Ensure workers are informed of any health surveillance, including the reason for the surveillance, by a competent person. Time should be allocated for questions and answers. Workers must be informed prior to the health surveillance commencing.

(17) Ask workers to sign a release of information form (provided by the medical practitioner or occupational hygienist). Without this form, the School/Unit will not be able to identify any opportunities to improve the health of workers.

(18) Carry out all health surveillance under the guidance of the Manager, Health Safety and Wellbeing.

(19) Ensure that no worker is subject to discrimination as the result of any test.

(20) Provide health surveillance reports to workers who have been tested for chemical exposure. Ensure workers only receive reports for their own health and not other workers.

(21) Explain to workers that their personal results will not be divulged to the University unless there are personal exposure results that must be addressed.

(22) The content of the examination will be determined by the nature of the workplace exposure, and its biological health effects. The following items are likely to be included:

  1. an employment history to determine work exposures and non-work related activities that may be relevant, i.e. smoking habits;
  2. chest X-rays;
  3. lung function tests;
  4. blood analysis;
  5. urinalysis;
  6. hearing tests; and/or
  7. radiation exposure evaluation.

Incident Reporting

(23) An incident report must be submitted using the University’s online incident reporting system in accordance with the Incident Reporting and Investigation procedure, if the report contains:

  1. any advice that test results indicate that the worker may have contracted a disease, injury or illness as a result of exposure; or
  2. any recommendation that the University take remedial measures, including whether the worker can continue to carry out the work with the hazardous chemicals.


(24) Review health surveillance results and provide follow up with the worker and their supervisor or manager.

(25) Retain the results of a worker’s health surveillance in accordance with regulatory standards – at least 30 years after the record is made.

(26) Limit access to a worker’s health surveillance records to the Division of People and Culture only. All the personal information relating to health surveillance must be treated as Medical-in-Confidence and must be kept strictly confidential.

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Section 5 - Guidelines

(27) Nil.