Health and Safety

Executive

Employment Medical Advisory Service

Health and Safety at Work etc Act 1974

Application to be appointed as an appointed doctor under

Regulations (Appointed doctors who are adding a company to an existing
Schedule do not need to complete Part 3)
Part 1 (to be completed by the occupier or their representative)
Name of doctor

Regulation(s) under which appointment is required

Name of company

Address(es) of workplace(s) to which the appointment relates

Name and position in firm

Signature Tel No Date

Part 2 (to be completed by the doctor - please allow at least 5 working days for processing requests to extend
an appointment to include additional regulations and/or a new company)
Name in full

Are you currently an appointed doctor or have you held an appointment previously?
Yes No If Yes, state your PIN number

Particulars of present duties at the factory or other place to which this application relates
Date of commencement Period of appointment Frequency and duration of visits

Duties

Whether remuneration is by salary or by fees and whether it includes a share in any profit or bonus of the firm

Details of any other financial interest in the firm, eg stocks, shares, patents, etc

How many employees work at the company? Male Female

How many employees require medical surveillance? Male Female

Type of work carried out by those employees requiring medical surveillance (eg asbestos stripping, demolition work
with potential exposure to lead, site radiography)

FODMS38AB (06.12)
Part 2 contʼd

For appointments under the Ionising Radiations Regulations 1999

Name of the dosimetry service

Name of the Radiation Protection Adviser

For appointments under the Control of Lead at Work Regulations 2002

Name of the laboratory performing lead measurements

Part 3 (to be completed by the doctor when seeking an appointment for the first time)

Name in full Date of birth Contact telephone number

Email address GMC number

Address to which official papers should be sent (to appear on a list of appointed doctors on HSE's website)

Private address and telephone number

Professional qualifications, with dates

Qualifications in Occupational Health

Training in Occupational Health (past and present)

Practical experience in Occupational Health

Part 3 contʼd

Details, with dates of commencement, of posts currently held (including general practice)

Part 4 Declaration
If appointed, I agree to accept the following conditions:
(a) That the duties required under the relevant regulations shall be punctually and faithfully performed by me or in my absence by an
Employment Medical Adviser / Medical Inspector or by a fully registered medical practitioner appointed for the purpose by the Health and
Safety Executive.
(b) That in carrying out the duties I shall comply with any administrative and clinical procedures recommended by the Head of EMAS.
(c) That I shall keep such records and provide such information as the Head of EMAS may prescribe.
(d) That I shall be prepared to undertake suitable refresher training relevant to these duties, if recommended by the Head of EMAS.
(e) That I shall, at such intervals as may be specified, provide a statement in the prescribed form of the examinations made in pursuance of the
relevant regulations.
*(f) That I have facilities for the measurement of pulmonary function (FEV and FVC as a minimum).
*(g) That I undertake to participate in the EMAS Survey of Asbestos Workers, if appropriate.
(h) That failure to observe any of these conditions may result in my appointment being revoked.
(i) That my name, address, telephone number and e-mail address will be included in a list of appointed doctors on HSEʼs website and I will
notify HSE of any changes to my contact details.

Signature Date

*Delete unless seeking appointment under the Control of Asbestos Regulations 2006.

The Data Protection Act 1998 requires the Health and Safety Executive (HSE) to inform you that this form may include information about you (this is called ʻpersonal dataʼ
in the Act) and that we are a ʻdata controllerʼ for the purposes of this Act. HSE will process the data for health, safety and environmental purposes. HSE may disclose
this data to any person or organisation for the purposes for which it was collected or where the Act allows disclosure. As data subject, you have the right to ask for a
copy of the data and to ask for any inaccurate data to be corrected