Chemical & Dust Hazardous Area

Name:
Department:

Do you aware that the company manufacturing area has any chemical & dust hazardous to your health?

Yes

No

How far your working place to the coating area?

I'm working in coating area

<10 meter

10-20 meter

>20 meter

How many times you entering coating area in a week?

How long time you spent each visit / passing by coating area?

<15 minutes/time

16-60 minutes/time

1-4 hours/time

>4 hours

Do u have symptoms of signs disease due to hazardous chemical / dust used?

No

Yes (please explain)__________________________________________________________

What kind of personal protective equipments you wear while entering coating area?

Safety shoe

Eye goggle

Face mask

Hand gloves

How many medical leave (MC) u take yearly?

None

1-5 days

5-10 days

More than 10 days

Any of that medical leave was related to working environment / condition?

No

1-3 times

4-10 times

Everytime

When the last time u do personal health screening / medical check up?

Never

Less than a year ago

Between 1 to 3 years ago

More than 3 years ago