HSE – Appointed Doctor for Ionising Radiation

We are currently able to do both face to face and paper-based certification under under the Ionising Radiations Regulations 2017  (please see below).
If you require a review, please have the questionnaire below completed and returned to helen@brydenmedical.com  along with the dose record and sickness absence record. Thanks.
The HSE issued new guidance on 3rd September 2020:

”Ionising Radiations Regulations 2017 (IRR)

For medical surveillance of classified persons, appointed doctors can resume routine practice. This includes paper reviews conducted remotely and face to face assessments where appropriate.”

If you require a review, please complete this questionnaire and email it to helen@brydenmedical.com, along with the dose record, sickness absence record and Health Record. Thanks.

IONISING RADIATIONS: TELEPHONE HEALTH REVIEW QUESTIONNAIRE

Name:__________________________ Date of Birth:_____________

Address_________________________________________________

Phone ______________Email _________________

Job Title_________________________________________________

1.        Please state briefly what your job consists of:
For the questions below, please tick “Yes or No” column and give details overleaf, as applicable No Yes
2.      Do you consider that you are in good health?If not, please give details overleaf.
3.      Have you, since your last medical examination at Occupational Health, been treated by your family doctor or specialist?If so, please state reason(s) overleaf.
4.      Have you been absent from work through illness in the past 12 months?If so, please give details of number of days absent and state overleaf the reasons and the approximate dates you were away.
5.      In the last 12 months, have you experienced:
·         Chest or breathing problems
·         Rashes or other skin problems
·         Anxiety, depression or other nervous or psychological problems
·         Any other health problems which you consider may affect your fitness to work with radiation or respiratory protection if required
If yes, please specify overleaf and indicate if these problems are still present or not.
6.        Have you, in the recent past, taken medicines regularly, or are you still doing so?If yes, please specify overleaf.
7.      Have you had to use any “over the counter” medication (including creams) more than once in the last year?(Describe overleaf).
8.      Do you use respiratory protective equipment (apart from in emergencies)If yes, please give details overleaf, particularly type of RPE used.
9.      Have you been involved in any incident which you incurred a higher radiation dose than usual or were contaminated?If so, please describe briefly overleaf.
10.  Has the nature of your work with radiation or sources of radiations changed in the last 12 months?If so, please state briefly in what way overleaf.
11.  Have you ever been exposed to any other carcinogenic agents at work?If yes, please give details overleaf.
12.  Have you ever had any special x-rays, scans (not MRI or ultrasound) or radiotherapy?If yes, please give details overleaf.
13.  With regard to your present state of health, do you feel you need to have a medical examination or see the Appointed Doctor?

Any other comments that you would like to make about your health?

 

To the best of my knowledge the information which I have given is correct. I give my consent to this medical assessment. I understand that the purpose of this medical is to provide information regarding fitness for work under the Ionising Radiation Regulations 2019 and that any advice given will be expressed in terms of fitness for employment and / or fitness to carry out duties now and in the future. I authorize the release of medical information from this assessment to my G.P. if necessary. I understand that confidential information about health and medical history will be confidentially treated, processed and stored in a secure environment by Bryden Medical Limited and will only be accessed and processed by those staff that have explicit and reasonable need to do so, with due consideration for Data Protection (GDPR 2018).

Signed: _________________________________Print  Name: _____________________________ Date: ___________________________________          

Please email completed forms and any questions to Dr Helen Bryden at helen@brydenmedical.com         Thank you.