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WHSMS Health and Air Monitoring Procedure

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Section 1 - Governing Policy

(1) This Procedure is governed by the Work, Health, Safety and Wellbeing Policy.

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Section 2 - Scope

(2) This Procedure applies to all staff, staff representatives, students, visitors, volunteers and contractors, and the working and learning activities which the University manages or influences.

(3) The legal requirements that are associated with Scheduled Substances have been excluded from the scope of this Procedure as the University disposed of its Scheduled Substances in 2019. However, those health monitoring requirements will be triggered if the University acquires Scheduled Substances.

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Section 3 - Background

(4) This Procedure supports the University to monitor its Work Health and Safety Management System (WHSMS or framework) and to verify that treatments (controls) to manage specific WHS risks are effective. This procedure also supports the University to comply with its legal obligations to initiate health and air monitoring and provide safe working and learning spaces.

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Section 4 - Preventive Approaches are a Priority

(5) Health monitoring should not be used as an alternative to the identification and management of WHS risks. This preventative approach is reinforced within this Procedure and the WHS Risk Management Procedure. These procedures communicate that the prevention of hazard exposures should be an overriding priority and that treatments (controls) to manage these threats should be documented within WHS risk assessments and associated treatment plans. Health and air monitoring requirements should also be included within the scope of the treatments that are selected to manage hazardous chemicals, gas, asbestos, lead and communicable diseases.

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Section 5 - When Should Health Monitoring be Triggered?

(6) Health monitoring will be conducted whenever health risks are identified and a medical practitioner, who has experience in health monitoring, has recommended a scientific and proven way to measure the effects of a health exposure.

(7) ACU also complies with its legal obligations to conduct health and air monitoring whenever anyone may have been/will be exposed to known physical hazards, noise, hazardous substances or a communicable disease.

(8) The initial monitoring activities, which may be undertaken to confirm whether treatments are effective or determine any potential exposures, will be centrally funded from the relevant organisational unit’s WHS overhead.

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Section 6 - Shared Responsibilities for Health and Air Monitoring

(9) Staff, students and contractors participate in health monitoring to support ACU to maintain its safe campuses and comply with its health monitoring duties and policy commitments. Staff and students will be informed by their Nominated Supervisors and other relevant staff about the possible health effects from exposure to hazards and the need to initiate health and air monitoring whenever this monitoring is conducted.

Table 1: An overview of health and air monitoring responsibilities

Who Roles and Responsibilities
Staff, staff representatives and students Participate in health monitoring whenever it is required and engage with any University consultations about health and air monitoring which may impact upon them or University processes. Staff also collaborate with Nominated Supervisors and others to develop and apply treatments that are informed by the results of monitoring.
Nominated Supervisors and Managers These staff may coordinate health monitoring activities and engage with staff, students, contractors and others about the need for health and air monitoring. They will also strengthen treatments whenever monitoring reports expose deficiencies in the ways that specific risks are treated. These staff also collaborate with relevant Executives, Incident Leads and health authorities to manage any communicable disease outbreaks.
Contractors Engage with the University’s two-way consultations about health and safety issues and comply with legal obligations to manage significant risks, conduct health and air monitoring, and collaborate with the University to comply with legal requirements which are associated with regulator notifications.
Properties and Facilities Engage with contractors about hazards and WHS risks, and ensure that contractors comply with their legal obligations to comply with health and air monitoring requirements. They also ensure that WHS risk assessments are conducted to identify hazardous activities, such as lead risk work, and ensure that significant WHS risks are managed.
Executive staff Ensure that significant risks are managed and the University complies with its legal obligations to initiate health and air monitoring and develop more robust treatments whenever adverse results are received. These staff also engage with relevant staff, staff representatives, students, contractors and others about health and air monitoring.
Employment Relations and Safety staff Collaborate with work areas to ensure that the University complies with its obligations to conduct health and air monitoring and retain records of monitoring. These staff also influence work areas to ensure that health and air monitoring is initiated to confirm that existing treatments, to manage specific WHS risks, are effective.
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Section 7 - Health and Air Monitoring Procedures for Hazardous Chemicals, Gas, Asbestos, Lead, Communicable Diseases, Legionella and Noise

(10) This section outlines the requirements for health and air monitoring that is associated with hazardous chemicals, gas, asbestos, lead, communicable diseases, legionella and noise.

Hazardous Chemicals

Air Monitoring Can Trigger Health Monitoring

(11) Relevant Nominated Supervisors and Managers, in collaboration with Facilities Management staff, should coordinate air monitoring activities after reviewing whether they are required. This monitoring should be conducted by an occupational hygienist, whenever:

  1. it is not certain whether the exposure standard for airborne contaminants has been exceeded; and
  2. a health risk has been identified during an incident investigation or the development of a WHS risk assessment and associated treatment (control) plan.

(12) This air monitoring will confirm whether any one has been exposed to a substance or a mixture within an airborne concentration, which exceeds the Safe Work Australia Workplace Exposure Standards: Airborne Contaminants 2018.

(13) This monitoring should measure the amount of a hazardous chemical or substance in the atmosphere within a working and learning area. The air monitoring will help determine the effectiveness of existing treatments (controls), the extent of any exposure(s) and will inform the assessment of WHS risks.

Annual Formaldehyde Testing

(14) The Manager Scientific Services should coordinate annual air testing of formaldehyde levels within anatomy laboratories. This testing is conducted using a colorimetric test.

(15) If the levels of formaldehyde exceed the Exposure Standards, another test will be conducted. If the results from the second test are consistent with the initial test, a review of the ventilation system will be coordinated by the local State Facilities Manager or Nominee.

Health Monitoring

(16) Health monitoring requirements should be documented within WHS risk assessments, and associated treatment plans should be developed by technical and other staff.

(17) Health monitoring should be provided to staff, students and others if it is determined that exposure to a hazardous substance could have exceeded the exposure standard. However, whenever risks are being treated in compliance with established practices for managing hazardous substances, including the recommendations of Safety Data Sheets (SDS), health monitoring would normally not be required.

(18) The chemicals that should be included with the scope of health monitoring include those substances that are known or presumed to be carcinogenic, mutagenic, toxic to human reproduction, respiratory or skin sensitizers.

(19) Health monitoring requirements may be triggered by an incident investigation (documented within a Riskware Action Plan) or the results of air monitoring. Health monitoring should also be conducted whenever staff and students are using hazardous substances and there is a significant risk that exposure levels have exceeded the Safe Work Australia Workplace Exposure Standards: Airborne Contaminants 2018 and there are valid techniques to determine these exposures (recommended by a medical practitioner who has relevant experience in health monitoring).

(20) If a spill of a known hazardous chemical occurs or there is a loss of containment, staff and students will also be offered health assessments, by the University or a relevant insurer, if ACU has a reasonable concern about an exposure, or the wellbeing of another person(s), or they have symptoms that are consistent with chemical exposures.

Gas Sources

Gas Monitoring

(21) Nominated Supervisors and Managers, in consultation with People and Capability WHS and Facilities Management staff, should undertake gas monitoring if there is a risk of a hazardous atmosphere, which may have resulted from an asphyxiant leak (resulting in oxygen falling to unsafe levels). A leak may also increase a risk of a fire and should be reported to the ACU National Security Centre on 8888 (internal phone) or 1300 729 452 as the Incident Convenor (critical incident management) should be notified.

(22) This monitoring should also be initiated if:

  1. The concentration of flammable gas (or vapour, mist or fume) exceeds 5% of the Lower Explosive Limit (LEL) for that gas;
  2. Combustible dust is present in a form or quantity that could ignite; or
  3. A strong smell of toxic gas (or identified by other means) suggests that gas could be have escaped and may exceed the exposure standard.

Asbestos

Identifying and Resolving Hazards

(23) WHS risk assessments should be conducted by Properties and Facilities staff or relevant contract Project Managers to help determine whether any Asbestos Containing Materials (ACM) are present and could be disturbed by the demolition or refurbishment of any structures or plant constructed prior to 2004. These assessments should be informed by the Hazardous Materials Register for the site and any new identification processes.

(24) If Properties and Facilities staff or Contract Project Managers determine that any ACM are likely to be disturbed, a licensed contractor will be used to remove these materials, prior to the commencement of refurbishment work, and the local HAZMAT Register should be updated by Properties and Facilities.

(25) Properties and Facilities staff will ensure the relevant WHS regulator is notified, by the licensed asbestos removalist, at least 5 days prior to the removal of the ACM.

Air Monitoring

(26) Air monitoring should be conducted for any ACM removal works in the following circumstances:

  1. It is likely the levels of exposure are higher than the Asbestos Exposure Standard;
  2. It cannot be determined whether the standard will be exceeded; and
  3. An independent licensed asbestos assessor determines it is required.

(27) Air monitoring should also be conducted in the event of an uncontrolled disturbance or release of asbestos. In these circumstances, the relevant WHS regulator should be notified within 24 hours of any removal works and a notifiable incident should be urgently reported.

(28) Properties and Facilities staff should ensure that an independent licensed asbestos assessor immediately conducts this monitoring within the asbestos removal area unless glove bags are used. The monitoring will continue throughout the asbestos removal work and until the area has been decontaminated, and prior to any enclosures being dismantled.

(29) A Clearance Certificate should be obtained prior to the commencement of other demolition or refurbishment work, or the reoccupation of the relevant working and learning area.

Asbestos Health Monitoring

(30) Health monitoring will be offered to staff, students, contractors and others by relevant contractors, contract Project Managers or ACU staff if there is a risk that they were exposed to asbestos fibres at levels which exceeded the Asbestos Exposure Standard.

(31) Properties and Facilities staff will confirm that health monitoring, via medical examinations, is being provided to contractors who are carrying out licenced asbestos removal work and have been exposed to ACM risks.

Lead

Background

(32) Lead can be found in high levels in buildings built prior to the 1980s in materials such as flashing, sheet lead, PVC products, lead solder, plumber fittings and paint that is flaking.

(33) Health monitoring is required whenever someone is performing lead risk work[1].

[1] Lead risk work: work carried out in a lead process that is likely to cause the blood lead level of a worker, including contractor, to exceed: 1) 30µg/dL (1.45 µmol/L); or 2) for females of reproductive capacity: 10ug/dL (0.48µmo/L).

Assessing WHS Risks and the Need for Monitoring

(34) A WHS risk assessment should be conducted by relevant campus Facilities Managers or Nominees, or contract Project Managers or Nominees for maintenance or construction work that involves a lead process. The scope of this assessment should include a determination about whether the work could be classified as a lead risk work that will result in potential lead exposures.

(35) If these exposure levels cannot be identified during this assessment the job should be classified as a lead risk work and effective treatments (controls) should be developed to manage this risk.

(36) Work, involving the following scenarios, may be classified as a lead risk work:

  1. Dry machine grinding, discing, buffing or cutting by power tools alloys containing more than 5% by work of lead metal;
  2. Machine sanding or buffing surfaces coated with paint (more than 1% of dry weight of lead);
  3. Welding, cutting or cleaning the surface of metal coated with lead or paint (containing more than 1% of dry weight of lead metal; and
  4. Other scenarios that are specified in WHS regulations.

(37) Whenever an activity is identified as lead risk work, relevant Properties and Facilities staff should ensure either the scope of the work is reduced to limit the threat of lead exposures or notify the Director, Properties and Facilities and collaborate with relevant staff or contractors to ensure the relevant State WHS regulator is notified, within seven days, about the job being lead risk work, which will trigger monitoring requirements.

Health Monitoring: Planned Activities Involving Staff and Contractors

(38) Any staff member or contractor conducting lead risk work will be required to participate in health monitoring, conducted by a suitably qualified practitioner, both prior to the commencement of this work and once again in a month’s time.

(39) Any staff member or contractor conducting lead risk work will be required to participate in health monitoring, conducted by a suitably qualified practitioner, both prior to the commencement of this work and once again in a month’s time.

Removing People from Harm

(40) Contractors or staff should be removed from harm and the ACU National Security Centre (refer to the Critical Incident Management Policy for more information) should be contacted, on 1300 729 452 or 8888 (internal phone)[2], if health and/or air monitoring reports show that:

  1. The airborne concentration of lead dust, lead mist or lead fumes are at levels that exceed 0·15 milligrams per cubic metre, (calculated as a time weighted average of the atmospheric concentration of lead over an 8-hour working day and a 40-hour working week); and
  2. Biological monitoring reveals the threshold of blood lead levels[3] has been reached.
[2] Whenever the ACU National Security Centre is contacted about a potential critical incident, the Incident Convener is initially notified. If the Incident Convener determines that the incident is a potential critical incident, the Incident Lead will be notified.
[3] Blood lead level thresholds:

2⋅41 µmol/L—for females not of reproductive capacity and males;
0⋅97 µmol/L—for females of reproductive capacity; and
0⋅72 µmol/L—for females who are pregnant or breast feeding.

(41) In the event that a medical practitioner recommends to the University that someone should be removed from harm, an Incident will be triggered within ACU, and the relevant Incident Convenor will assess – in collaboration with relevant staff - whether other people are likely to be impacted and determine whether other people should be removed from harm.

(42) Properties and Facilities staff should also:

  1. Reassure the Incident Convenor that the area is safe;
  2. Collaborate with contractors and People and Capability staff to ensure the relevant state WHS regulator is immediately notified; and
  3. The University should provide two medical examinations (the first one immediately and the second within 30 days), in collaboration with any relevant workers’ compensation insurers, to anyone that may have been exposed. If it is determined that blood lead exceeds lead threshold levels, ongoing tests should be scheduled according to the recommendations of the medical practitioner that has experience in health monitoring.

(43) People and Capability staff will also collaborate with relevant Properties and Facilities staff and the Incident Convenor to ensure the relevant WHS regulator is provided with a copy of the health monitoring report if relevant blood lead levels have been reached or exceeded, or the tests results indicate that a person has contracted a disease, injury or illness which resulted from a working activity.

Communicable Diseases Exposures

Assess the need for health monitoring

(44) Whenever someone has been diagnosed with a communicable disease, the following steps should be taken to assess the need for health monitoring and reduce any additional exposure risks:

Task No. Task Responsibility (In most cases, this will be a Member of a Critical Incident Response Group /Incident Response Group, or at the Group’s direction) When
1.
Determine: Whether the relevant State health authority has been notified about the diagnosis by a relevant practitioner or hospital?
Yes: Proceed to Step 2
No: Ensure that the relevant health authority is notified. Proceed to Step 2.
Relevant Executive or Nominee Immediately
2.
Call the ACU National Security Centre on 8888 or 1300 729 452 who will ensure that the relevant Incident Convenor (IC) is notified. The Incident Convenor will notify the Incident Lead.
Complete the Riskware Action Plan for the incident.
Relevant Executive or Nominee Immediately
3.
Determine who could have been exposed or is at risk of exposure and reference the relevant materials about the disease, published by relevant health authorities.
Relevant Executive or Nominee Promptly
4.
Consult with the relevant health authority. Is health screening required (staff, students and other exposed people)?
Yes: Proceed to Step 6
No: Go to Step 5 (bypass Steps 6 and 7)
Relevant Executive or Nominee Promptly
5. Email or communicate with anyone that was potentially exposed to the communicable disease and prompt these people to visit their practitioner if they are experiencing symptoms which could indicate that exposure has occurred. Relevant Executive or Nominee Promptly
6. Collaborate with Properties and Facilities to decontaminate/disinfect relevant working and learning areas (if required) Relevant Executive or Nominee in collaboration with relevant State Facilities Manager or Nominee Promptly
7. Develop and distribute communications about the health screening, to be distributed to anyone that has a high risk of exposure Relevant Executive or Nominee Timeline determined by relevant health authority
8. Coordinate health screening in collaboration with the relevant State health authority
9. Consult with People and Capability WHS staff and Health Authorities about managing the risks which are associated with anyone that has been diagnosed with a communicable disease. Relevant Executive or Nominee Promptly

Legionella Exposure

Legionella and its source

(45) Legionella is a bacterium that leads to a type of pneumonia known as Legionnaire’s Disease. It is usually contracted by breathing in mist from water that contains the bacteria. The potential source of bacteria-laden water mist on ACU campuses is cooling towers.

Legislation and other requirements

(46) Legislation in New South Wales and Victoria prescribe the management of the risks associated with cooling towers and stipulate specific monitoring, reporting and action requirements. ACT legislation identifies its Public Health Cooling Towers, Evaporative Condensers and Warm Water Storage Systems Code of Practice 2005 as mandatory, which in turn adopts AS/NZS 3666 – Air handling and water systems of buildings Part 1 to 3. Queensland has no specific legislation relating to cooling towers, however, they will be managed in compliance with this standard and AS 3896.2017 (legionellae examination).

(47) ACU shall ensure that competent contractors are directly engaged to undertake all aspects of cooling tower management.

Cooling Tower Risk Management (NSW)

(48) The Director, Properties and Facilities should ensure that a risk assessment is in place for each cooling tower. The Director, Properties and Facilities shall also ensure that periodic risk assessments are undertaken, by a competent person, in accordance with the risk classification provided in the initial risk assessment, as follows:

  1. For cooling towers classified as high risk, a risk assessment shall be conducted at least every 12 months;
  2. For cooling towers classified as low or medium risk, a risk assessment shall be conducted at least every 60 months.

(49) Once the risk assessment has been completed, the Director, Properties and Facilities shall ensure the local council is informed in the approved format within seven days (this requirement varies from state to state).

(50) The Director, Properties and Facilities shall also ensure an independent audit of compliance with the risk assessment undertaken at least every 12 months.

Cooling Tower Risk Management (VIC)

(51) ACU shall ensure a risk management plan is in place for each cooling tower. The risk management plan must:

  1. Address the risks and set out the steps to be taken to manage the risks;
  2. Set out the steps taken to ensure compliance with risk management requirements;
  3. Be in the approved form;
  4. Address the risks associated with the listed requirements in the Regulations; and
  5. Be reviewed, and if necessary updated, at least once every 12 months.

(52) ACU shall ensure that a risk assessment is in place for each cooling tower. The risk assessment must include:

  1. The make, model and serial number of each cooling tower;
  2. Identification of the sampling point from where all regular water sampling occurs;
  3. An assessment of all risk factors detailed in Table 2.1 of AS/NZS 3666.3 for each cooling tower;
  4. A statement of the performance criteria and operating control ranges for total alkalinity, chlorides, conductivity/TDS, pH and temperature on each cooling tower;
  5. An outline of the chemical and physical parameters required for the effective operation of the selected biocide;
  6. A statement of how the water sampling regime is linked to the monitoring program and the effectiveness of the selected water treatment approach.

(53) ACU shall ensure the risk assessment is conducted at least every five years, or as otherwise directed.

Cooling Tower Sampling, Testing and Inspection

(54) ACU shall engage a competent person to undertake sampling, testing and inspection at least once a month. They shall:

  1. Take samples of water from the cooling water system;
  2. Inspect the cooling water system;
  3. Carry out a chemical analysis of the cooling water system;
  4. Have the samples tested for Legionella and heterotrophic colony count (HCC), in a laboratory accredited by the National Association of Testing Authorities (NATA); and
  5. Prepare a report in the approved format and provide a copy to ACU.
Reporting and Action

(55) The reporting and action threshold requirements in relation to legionella and HCC concentrations vary from state to state. It is important that ACU engages competent contractors familiar with the requirements for the state in which the cooling tower is located, to ensure that ACU meets its legal obligations. It is also important that ACU is aware of those obligations and ensures scheduled tasks are completed on-time by the contractor.

Noise

Exposure levels

(56) ACU shall ensure that staff are not exposed to noise levels that exceed the exposure standard:

  1. LAeq,8h of 85 dB(A); or
  2. LC,peak of 140 dB(C)[4].
[4] LAeq,8h means the eight-hour equivalent continuous A-weighted sound pressure level in decibels (dB(A)) referenced to 20 micropascals. LC,peak means the C-weighted peak sound pressure level in decibels (dB(C)) referenced to 20 micropascals. Both sound pressure levels are determined in accordance with AS/NZS 1269.1:2005 Occupational noise management - Measurement and assessment of noise emission and exposure.

Noise measurement

(57) The exposure standard noise levels may be exceeded in areas such as plant rooms or during work activities, such as percussive drilling. In these or similar circumstances, ACU shall ensure a noise assessment is undertaken by a competent person to establish the actual noise levels that staff are exposed to.

Control measures

(58) Where the noise cannot be eliminated, reduced or otherwise controlled to below the exposure standard, appropriate hearing protection shall be provided by ACU to staff exposed to the noise. In addition, and where practical to do so, mandatory hearing protection signage shall be erected, such as at the entry points to plant rooms.

Audiometric Testing

(59) Where hearing protection is required to be worn by staff, ACU shall:

  1. Provide audiometric testing within three months of a staff member starting work and at least every two years;
  2. Provide a staff member with an audiological examination as soon as is reasonably possible if two or more tests during a period not exceeding two years indicate a reduction in hearing levels equal to or greater than 15dB at 3000 Hz, 4000 Hz or 6000 Hz;
  3. Ensure the person who conducts an audiological examination provides a report to the employer containing the results and stating whether hearing loss has occurred; and
  4. Keep test results or examination report for the period of the employee's employment.
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Section 8 - Engaging Relevant Staff about Health Monitoring Requirements

(60) Relevant People and Capability WHS staff should be consulted about health monitoring reports and the reports should be provided to the impacted person(s) as soon as possible.

(61) If an adverse health monitoring result is received, which relates to an exposure within the University, actions should be taken to minimise any further risks to the health and safety of the person, and the Employee Assistance Program (EAP) should be offered to any impacted staff members. People and Capability WHS staff will also discuss workers compensation options with any impacted staff.

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Section 9 - Engaging Students about Health Monitoring Requirements

(62) Relevant student supervisors or Laboratory Managers should inform their Nominated Supervisor, relevant People and Capability WHS Staff of an identified potential need to provide health monitoring to a student(s).

(63) Whenever health monitoring is offered to a student, the relevant Executive or delegate shall meet with the student (and their guardian if the student is under 18 years of age) and advise them of the importance of undertaking a program of health monitoring which will be coordinated by ACU.

(64) In the event that an adverse health monitoring report is received: student counselling services will be offered to any affected student(s).

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Section 10 - Mandatory Notifications to WHS Regulators

(65) People and Capability WHS staff will also contact the relevant WHS regulator or confirm with Properties and Facilities staff that the regulator has been provided with a relevant health monitoring report, whenever:

  1. Advice or test results that indicate the person tested may have contacted a disease, illness or injury due to a working activity that triggered the health monitoring; and
  2. Any recommendation received about taking remedial measures, including any recommendations about whether a staff member can continue to perform their existing duties.
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Section 11 - Health and Air Monitoring Records

Air Monitoring Records

(66) Air monitoring records should be uploaded to the HPE Content Manager (refer to WHSMS Records and Document Management Procedure) by relevant Properties and Facilities staff to ensure that they are accessible to the relevant organisational unit who requested the testing.

(67) Health monitoring records for visitors and volunteers should also be uploaded to the HPE Content Manager by the relevant organisational unit. Refer to the WHSMS Records and Document Management Procedure for the naming convention and recommended file paths.

Staff Health Monitoring Reports

(68) Health monitoring reports and records must be accurately maintained for at least 30 years and asbestos records must be held for 40 years.

(69) Whenever health monitoring has been undertaken for staff, the relevant Nominated Supervisor will obtain a health monitoring report from the registered medical practitioner who carried out the health monitoring. The relevant staff member will be given access to the report and Nominated Supervisors will discuss the report and any actions taken to remove the staff member from harm or remove/mitigate the hazard from the workplace.

(70) The relevant Nominated Supervisor shall ensure that a copy of the health monitoring report and any other relevant records are submitted to Service Central.

(71) Health monitoring reports and any test results must be kept as a confidential record, within the relevant employment/staff record, and must not be disclosed to another person without the staff members’ written consent (which should also be attached to a relevant staff record), except when these records will be disclosed to an authority.

Student Records

(72) Health monitoring reports for students will be maintained, confidentially, for a period of least 30 years (and asbestos records that must be retained for 40 years) and will be placed on the Banner Document Management System by Student Administration staff.

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Section 12 - Revisions made to this Procedure

(73) The revision table includes revisions up until this document was migrated into the current policy platform. Any later changes will show in the Status and Details tab. 

Date Major, Minor or Editorial Description
20 January 2020 Minor The scope of the procedure has been broadened to include legionella exposure and noise.

(74) The University may make changes to this Procedure from time to time to improve its effectiveness. If any staff member wishes to make any comments about this Procedure, they should forward their suggestions to People and Capability.

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Section 13 - Further Assistance

(75) Any staff member who requires assistance in understanding this Procedure should first consult their Nominated Supervisor or Manager who is responsible for applying the University’s WHSMS within their work area. Should further information or advice be required staff should visit Service Central.

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Section 14 - Associated Information

(76) For related legislation, policies, procedures and guidelines and any supporting resources, please refer to the Associated Information tab.