• Asbestos Pre-Appointment Medical Questionnaire

    For Workers Undertaking Licensed Work with Asbestos (excluding firefighters)
  • When is your appointment*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Date of Birth (DD/MM/YYYY)*
     - -

  • Asbestos Workers' Survey:

    Consent Form
  • By agreeing to take part in the Asbestos Worker's Survey, I am confirming that:
  • 1. I have read the worker information leaflet dated April 2026 (version 04.26) for this study. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily.
  • 2. I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason, without my medical care or legal rights being affected.
  • 3. I understand that data collected during the study may be looked at by individuals from HSE or from regulatory authorities, where it is relevant to my taking part in this research. I give permission for these individuals to have access to my records.
  • 4. I understand that other health researchers from outside HSE may use information collected during this study. My name, address and any other information that may identify me will be removed before sharing.
  • 5. I understand that information held and maintained by NHS England (England and Wales) or the NHS Central Register (Scotland) may be used to help contact me or provide information about my health status.
  • I agree to take part in this study (please initial one box only)*
  • (Optional) Other research. Occasionally HSE may wish to invite you to take part in other research about the health or experience of asbestos workers in Britain. We would write to you at the home address you provide in the following questionnaire. Would you be happy to be contacted about other relevant research? (please initial one box)

  • Asbestos Workers' Survey: Questionnaire

  • Section 1: Personal Details

  • Date of Birth (DD/MM/YYYY)*
     - -

  • Section 2: Worker Details

  • Is this your first medical before starting work with asbestos with your current employer? (please cross one box)
  • At birth, were you described as (please cross one box)*
  • What is todays date?*
     - -

  • Section 3: Smoking Details

  • Have you EVER smoked tobacco?
  • Do / did you mainly smoke cigarettes?
  • Have you ever tried vaping / e-cigarettes?

  • Section 4: Asbestos Work Details

  • Section 5: Job Details

  • Please complete the sections below about the work you do.

    If you have not yet started working with asbestos at your current employment: You may not be able to give answers to some of the following questions. Please complete the following questions as best you can based on your understanding of the work you will be doing.

  • Section 5a: Asbestos stripping or removal work

  • Do you undertake any asbestos stripping or removal work? (please cross one box)*
  • What type of asbestos stripping or removal work do you undertake? (please cross all that apply)
  • How often do you normally work with the following asbestos-containing materials when stripping? (please cross one box on each row)
    Rows
  • How often do you normally work with the following other asbestos-containing materials when stripping? (please cross one box on each row)
    Rows
  • What kind of respirator do you use when stripping? (please see examples vis this link https://www.hse.gov.uk/forms/health/fodms75-reference.pdf and cross all that apply)
  • How often do you dry strip?
  • When dry stripping, what dust control measure do you normally use? (please cross all that apply)

  • Section 5b: Other work with asbestos

  • Do you undertake any other work involving asbestos which is not stripping or removing asbestos? (please cross one box)*

  • What type of other work with asbestos do you undertake?

    (please cross all that apply)

  • Building and Construction

  • What type of other work with asbestos do you undertake?

    (please cross all that apply)

  • Other processes
  • How often do you normally work with the following asbestos-containing materials? (please cross one box on each row)
    Rows

  • If you crossed NEVER on every row, please skip Question 37

  • How often do you normally work with the following other asbestos-containing materials? (please cross one box on each row)
    Rows

  • Section 6: Current Health Status (EQ5D)

    Under each heading, please tick the ONE box that best describes your health TODAY.
  • MOBILITY
  • SELF-CARE
  • USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities)
  • PAIN / DISCOMFORT
  • ANXIETY / DEPRESSION

  • How would you rate your health today?

    100 means the best health you can imagine.
    0 means the worst health you can imagine.

  • Section 7: Health Questionnaire

  • Has a doctor ever told you that you have an asbestos-related health condition? (Please cross one box)
  • In the following set of questions*, please go through the questions in order from (a) to (e) and cross the YES boxes that describe you. If you answer NO at any point, please go to Q42 (please cross one box)
    Rows
  • How is your general health? (please cross one)
  • Thank you for agreeing to take part in this research and for taking the time to complete this questionnaire.

  • Respiratory Symptom Questionnaire - Licensed Work

  • Have you ever, or since your last examination had an injury or operation affecting your chest?*
  • Have you ever, or since your last examination had pleurisy?*
  • Have you ever, or since your last examination had pulmonary tuberculosis?*
  • Do you usually cough during the day (or at night when on night work)?*
  • Do you usually bring up any phlegm from your chest on most days (or nights) for as much as three months each year?*
  • Do you usually get short of breath when walking with people of your own age on level ground?*
  • During the past three years, or since your last examination, have you had any chest illness, which has kept you from your usual activities for as much as a week?*
  • Did you bring up more phlegm than usual in any of these illnesses?*
  • Have you ever smoked?*
  • Do you smoke at present?*
  • Have you given up smoking in the last month?*

  • End of Form

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