CNC Medical Surveillance Onboarding

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 on this Plan (what this person is our contact about, for example occupational health, HR, site safety)

Full name

Job title at your company (for example SHE Officer, HR Manager)

Email

Telephone

2. REGULATORY AND COMPLIANCE CONTEXT

The regulations below start out ticked. Untick anything that does not apply to your operations. The list is not exhaustive, so 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 Exposure Regulations, 2024 (these replaced the Noise Induced Hearing Loss Regulations, 2003 from 6 September 2026)

Work with asbestos

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.

Attachments are not saved with your draft. Everything you type is remembered on this device, but a browser will not let a page put a file back into an upload box. If you close the page before submitting, the documents need attaching again.

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. Each block carries the full hazard key as tick boxes, so there is nothing to look up and nothing to type. Tick every hazard that applies to that job. Where a hazard says "specify in notes", put the detail in the box below.

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

Job categories (at least one is required; one block per category, leave unused blocks blank)

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

Choose your industry, then the area of work that best describes your operation. If none fits, choose Other and describe your business below; an Other selection routes to human review and never auto generates.

Industry (required)

Area of work (required)

If OTHER, describe your industry and core activities

9. BRANDING AND DELIVERY

Attachments are not saved with your draft. If you close the page before submitting, your logo needs attaching again.

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

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)

Client Onboarding