Reporting form for people potentially exposed to substances that can cause occupational asthma.
Employee's name.................................................. Staff / Student (delete as necessary)
Department............................................................
Contact details........................................................
I am exposed to the following at work or in my studies...................................................
I wish to report the following symptoms:
(a) Recurring soreness of or watering of eyes
(b) Recurring blocked or running nose
(c) Bouts of coughing
(d) Chest tightness
(e) Wheeze
(f) Breathlessness
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

(g) I have consulted my doctor about chest problems since the last questionnaire? Yes

No

(h) Skin problems
(i) Other

Yes

No

Please give details of other symptoms........................................................................................

Date of onset of these symptoms.................................................................................................
What I think is causing these symptoms......................................................................................
Other comments.............................................................................................................
.............
Signed..........................................
Date.............................................
Note to responsible Manager/tutor:
The receipt of this form from an exposed person must immediately result in referral to
OH using a health surveillance referral form