Occupational Health Record - Nova Scotia Health Authority Page 2
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23. Have you had exposure to any of the following hazards without use of recommended Personal Protective Equipment
(PPE). If yes, please explain:
□
□
Chemicals
Yes
No
__________________________________________________________
□
□
Noise
Yes
No
__________________________________________________________
□
□
Radiation
Yes
No
__________________________________________________________
4.
Allergies and/or Sensitivities:
□
□
Latex
Yes
No
___________________________________________________________
□
□
Drugs
Yes
No
___________________________________________________________
□
□
Chemicals
Yes
No
___________________________________________________________
□
□
Insect Stings
Yes
No
___________________________________________________________
□
□
Fragrances
Yes
No
___________________________________________________________
□
□
Other
Yes
No
___________________________________________________________
I understand that the Occupational Health Nurse is collecting this information for the purpose of
determining if my health and health history pose any limitations/restrictions that may interfere in my
ability to perform the essential duties of a job that I have applied for. The Occupational Health Nurse will
keep all personal health information on this form confidential; only fitness to work information will be
provided to my employer
I hereby declare that this information is true and complete to the best of my knowledge and that
intentionally leaving out any relevant information may be grounds for immediate and automatic
termination of employment.
Applicant Signature: ________________________
Date (YYYY/MM/DD): __________________
Rev May 2017
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