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Medical Surveillance Form - Licensed Asbestos Work (UK) Mobile App

The Medical Surveillance Form - Licensed Asbestos Work (UK) mobile app allows asbestos workers in the United Kingdom to completes an HSE medical consent form using a smartphone or tablet. GoCanvas supports signature capture.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Medical Surveillance Form - Licensed Asbestos Work (UK) Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    Please read the HSE information leaflet about the research before completing this form

  • Ico statictext

    Britain in order to inform future policy decisions regarding regulations for working with asbestos.

  • Ico statictext

    All of the information gathered in these forms is for research purposes only and will be kept in ...

  • Ico statictext

    Personal identifiable data will only be used to link details of health outcomes (recorded on the ...

  • Ico statictext

    No information about you will be identifiable in the results of the research.

  • Ico statictext

    Please choose ONE of the following two options (please tick)

  • Ico statictext

    Yes - I confirm that I have read and understood the HSE information leaflet and I would like to ...

  • Ico checkbox

    I understand that the information held and maintained by The Health and Social Care Information C...

  • Ico checkbox

    I understand my participation is voluntary and that I am free to withdraw at any time, without gi...

  • Ico statictext

    Thank you - the doctor will now complete

  • Ico checkbox

    No - I confirm that I have read and understood the HSE information leaflet and I do not wish to ...

  • Ico statictext

    It would still be useful to the researchers if you would complete the reverse of the MS75 form WI...

  • Ico statictext

    Thank you

  • Ico signature

    Signed

  • Ico date

    Date

  • Ico textbox

    Name

  • Ico date

    Date of birth

  • Ico statictext

    This study has been reviewed and given favourable opinion by the National Research Ethics Service...

  • Ico textbox

    Dr’s PIN number

  • Ico textbox

    NI number

  • Ico date

    Date of birth

  • Ico textbox

    NHS No

  • Ico textbox

    Forename

  • Ico textbox

    Surname

  • Ico textbox

    Maiden/Previous Name

  • Ico textbox

    GP’s name

  • Ico textbox

    Place of birth

  • Ico multiline

    Worker’s address

  • ...and More!

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