CNC Medical Surveillance Onboarding

This form gathers the information Care Net Consultants (Pty) Ltd requires to design an accurate, client specific Medical Surveillance Plan for your organisation. Care Net designs your Plan based entirely on the information you provide here and does not independently conduct your workplace risk assessment. Do not enter any employee identity number, any name linked to a medical condition, or other personal information about an identifiable individual anywhere in this form.

1. COMPANY AND SITE DETAILS

Registered company name (required)

Trading name (if different)

Company registration number (required)

VAT registration number

Registered or head office address (required)

Core industry or nature of business (required)

Years operating at the listed sites (required)

Sites covered by this Plan (one block per site; leave unused blocks blank)

site 1

Site name

Site address

Nature of activity at this site

Approximate number of employees

Primary contacts

contact 1

Role (for example SHE Officer, HR Manager)

Full name

Position

Telephone

2. REGULATORY AND COMPLIANCE CONTEXT

Tick every regulation that applies to your operations. This is not an exhaustive list; add any other sector specific regulation in the space provided.

Occupational Health and Safety Act 85 of 1993 (General Safety and General Administrative Regulations)

Construction Regulations, 2014

Mine Health and Safety Act 29 of 1996

Hazardous Chemical Agents Regulations, 2021

Noise-Induced Hearing Loss Regulations / Noise Exposure Regulations

Asbestos Abatement Regulations

Lead Regulations

Hazardous Biological Agents Regulations

Ergonomics Regulations, 2019

National Road Traffic Act and Professional Driving Permit requirements

Code of Good Practice: Arrangement of Working Time (night or shift work)

Other applicable regulations, please specify

Registered for COIDA (tick if yes)

COIDA class, tariff, or assessment number if known

Any enforcement, prohibition, or improvement notice from a regulator in the past three years (tick if yes)

If yes: date, issuing authority, nature of notice, resolution status

Any principal contractor, client, or third party requiring a specific medical certificate format or validity period (tick if yes)

If yes: the third party, the certificate requirement, and the validity period

3. EXISTING RISK ASSESSMENT AND OCCUPATIONAL HYGIENE INFORMATION

This section is the foundation of your Medical Surveillance Plan. Care Net relies on the information and documents provided here. Attach the documents referred to.

Current workplace health and safety risk assessment in place (tick if yes)

Date the risk assessment was conducted

Conducted by (name and company or Approved Inspection Authority)

Qualification or accreditation of the assessor

Date of next scheduled risk assessment review

Attach the risk assessment

Occupational hygiene monitoring results available (tick if yes)

Date of the most recent hygiene survey

Conducted by (name and company, accreditation)

Attach the hygiene monitoring results

Any change in process, plant, materials, or job content since the last risk assessment (tick if yes)

If yes, describe the change

Attach Safety Data Sheets

Quantified exposure levels, if known (one block per measurement)

exposure 1

Hazard and location

Measured level

Unit

Occupational Exposure Limit, if known

Date measured

4. WORKFORCE PROFILE

Total number of employees covered by this Plan (required)

Permanent employees

Contract employees

Temporary or seasonal employees

Employees work rotating shifts or night work (tick if yes)

If yes, describe the shift pattern

Night work medicals currently conducted per the Code of Good Practice (tick if yes)

Current night work medical repeat interval

Any employees under the age of 18 (tick if yes)

Any employees currently pregnant or breastfeeding in a role with occupational exposure (tick if yes)

Active health and safety committee or union representation on site (tick if yes)

At an aggregate level, employees in exposed high risk roles with chronic conditions that could cause sudden incapacity (tick if yes; never name any individual)

If yes, list the affected job categories only. Do not name any person and do not enter any identity number.

5. JOB CATEGORIES AND EXPOSURE IDENTIFICATION

Complete one block per job title or category. Hazard key: A Noise. B Dust or respirable crystalline silica. C Hazardous chemicals (specify in notes). D Biological agents. E Working at height above 1.5m. F Confined spaces. G Vibration. H Heat or thermal stress. I Manual handling or ergonomic strain. J Driving (licence or PrDP class in notes). K Shift or night work. L Ionising or non ionising radiation. M Electrical hazard. N Psychosocial hazard. O Other (specify in notes).

Additional detail on specific hazards not captured above (known noise or dust levels, height of work, vehicle classes, and so on)

Job categories (one block per category; leave unused blocks blank)

job 1

Job title or category

Number of employees

Brief description of duties

Hazard letters from the key, separated by commas (for example A, B, E)

Existing controls (engineering, administrative, PPE)

Physical demands of the job itself (for example lifting, standing, climbing)

Sensory and cognitive demands (for example vision, hearing, concentration)

Statutory or competency requirement (for example PrDP class, heights ticket)

RPE issued (state type, or None)

RPE fit tested (Yes, No, or Not applicable)

Fit test interval

Other PPE issued and inspection interval

Chemical and hazardous substance register (one block per substance; attach SDS rather than retyping)

chem 1

Chemical or substance name

SDS reference number

Task or process

Frequency of use

Quantity per use

Control measures in place

6. CURRENT MEDICAL SURVEILLANCE ARRANGEMENTS

Employees currently undergo occupational medical examinations (tick if yes)

Current service provider, if any

Date of the most recent medical surveillance cycle

Tests currently performed and how often, if known

Outstanding referrals or unresolved abnormal findings from a previous provider (tick if yes)

Current medical records format

7. INCIDENT AND OCCUPATIONAL DISEASE HISTORY

Reported work related injuries in the past three years (tick if yes)

COIDA claims submitted in the past three years for an occupational disease (tick if yes)

Any employees currently on modified or restricted duties for health reasons (tick if yes)

Brief details for any yes answer above (no individual names, no identity numbers)

8. INDUSTRY AND SUBINDUSTRY SELECTION

Select from the governed list. Currently selectable: CONSTR-CIVILS, CONSTR-BUILD, CONSTR-DEMO (demolition), CONSTR-ELEC (electrical construction), CONSTR-ROADS (roadworks), MANU-FOOD, MANU-METAL, MANU-CHEM (chemical), MANU-AUTO (automotive), MANU-TEX (textiles), MANU-PLASTIC (plastics), MANU-WOOD (wood and furniture), MIN-GOLD, MIN-QUARRY, MIN-COAL, MIN-PLAT (platinum), MIN-CHROME, MIN-DIAMOND, TRANS-ROAD, TRANS-WARE, TRANS-RAIL, TRANS-PORT (ports and terminals), TRANS-AVGH (aviation ground handling), AGRI-CROP, AGRI-LIVE (livestock), AGRI-FOREST (forestry), HLTH-CLINIC (clinics and practices), HLTH-LAB (laboratories), HLTH-HOSP (hospitals), UTIL-GEN (power generation), UTIL-WATER (water and wastewater), UTIL-RENEW (renewable energy), SEC-GUARD, SEC-ARMED (armed response and cash in transit), CLEAN-COMM, CLEAN-SPEC (specialised hygiene), RET-STORE, RET-WHOLE (wholesale and distribution), HOSP-ACCOM (hotels), HOSP-FOOD (restaurants and catering), WASTE-COLL (collection), WASTE-SITE (landfill and transfer), WASTE-REC (recycling), TEL-TOWER (tower work), TEL-FIELD (field network services), TEL-DC (data centres), PETRO-BULK (refining and terminals), PETRO-RETAIL (service stations), PETRO-GAS (LPG and industrial gases), GOV-ADMIN (municipal administration), GOV-WORKS (public works), GOV-EMERG (emergency and traffic services), EDU-SCHOOL (schools and early childhood), EDU-TERTIARY (tertiary and training), OFF-CORP (corporate offices), OFF-CALL (contact centres). If your industry is not listed, enter OTHER and describe your business; an OTHER selection routes to human review and never auto generates.

Industry code (CONSTR, MANU, MINING, TRANS, AGRI, HEALTH, UTIL, SEC, CLEAN, RETAIL, HOSP, WASTE, TEL, PETRO, GOV, EDU, OFFICE, or OTHER) (required)

Subindustry code (see the selectable list above, or OTHER) (required)

If OTHER, describe your industry and core activities

9. BRANDING AND DELIVERY

Company logo upload (PNG or SVG, minimum 600 pixels wide, transparent background preferred) (required)

Brand colour, if you have one (hex value, for example #003366)

Preferred certificate format, if any

Delivery contact full name (required)

Delivery contact email (required)

10. DATA PROTECTION AND CONSENT

Care Net Consultants (Pty) Ltd processes the information in this questionnaire for the sole specified purpose of designing your organisation's medical surveillance programme, in accordance with the Protection of Personal Information Act 4 of 2013. You may withdraw consent at any time by contacting the Care Net Information Officer. This form must not contain any employee's identity number, medical condition, or other personal information about an identifiable individual.

Your organisation's Information Officer or Deputy Information Officer (required)

Email or telephone for the Information Officer (required)

Employees will be informed of this programme and their POPIA rights before their first examination (tick to confirm) (required)

REQUIRED: I consent to Care Net Consultants (Pty) Ltd processing the information in this questionnaire for the sole purpose of designing our medical surveillance programme, under the Protection of Personal Information Act 4 of 2013. Withdrawal: contact the Care Net Information Officer. (required)

OPTIONAL and separate: I consent to Care Net Consultants (Pty) Ltd sending our organisation information about related occupational health services. This is not required for your Plan and is off unless ticked.

Tick to use Care Net's standard POPIA employee notice and consent forms; leave blank to provide your own

11. DECLARATION

I confirm that the information provided in this questionnaire, and any documents attached to it, is accurate and complete to the best of my knowledge at the date of signature. I understand that Care Net Consultants (Pty) Ltd will design the organisation's Medical Surveillance Plan based on this information and any risk assessment or hygiene monitoring documents attached, and that Care Net does not independently conduct the underlying workplace risk assessment as part of this process. I undertake to notify Care Net promptly of any change in process, plant, materials, job content, or risk assessment findings that may affect the accuracy of the resulting Plan.

Full name (required)

Position (required)

Company (required)

Signature (required)

Date (required)