Health surveillance policy

Reference: TBC
Version number: 1
Effective from: 01/03/2020
Approval date: 
Review date: 01/02/2023
Author: Sarah van Zoelen

1 - Overview

1.1 Purpose

It is the policy of Loughborough University to ensure that no harm comes to staff or others who use hazardous products, equipment and materials. Where guidance in legislation does not exist best practice, as advised by the Health and Safety Executive will be indicated.

Risks can be associated with hazardous chemicals, biological agents, noise, vibration, although exposure to trace quantities or irritant substances will only cause harm if exposure occurs frequently.

1.2 Scope

This policy applies to all work involving the use of hazardous materials, biological agents, vibrating tools and noise. Ensuring that the necessary controls are in place to prevent, or where this is not possible, to reduce the risk so far as is reasonably practicable to human health and safety.

The policy applies to all staff, students (both postgraduate and undergraduate) and personnel (e.g. contractors) at workplaces under the control of Loughborough University.

1.3 Definitions

Health Surveillance: a program of ongoing health checks. Some of which are required by legislation, some are best practice to prevent work place ill health and enable the early detection of work related conditions.

The HSE stated that Health surveillance is important for:

  • detecting ill-health effects at an early stage, so employers can introduce better controls to prevent them getting worse
  • providing data to help employers evaluate health risks
  • enabling employees to raise concerns about how work affects their health
  • highlighting lapses in workplace control measures, therefore providing invaluable feedback to the risk assessment
  • providing an opportunity to reinforce training and education of employees (eg on the impact of health effects and the use of protective equipment)

Where it is considered that health surveillance is required, the school or service will be required to re-assess their activity to identify control measures, potential, extent and duration of exposures along with determining if safer practices could be implemented. The risk assessment should be used to identify any need for health surveillance.  You should not use health surveillance as a substitute for undertaking a risk assessment or using effective controls.

1.4 Is Health Surveillance compulsory?

Yes, all health surveillance is compulsory as it is implemented in line with legislation and is required to safeguard the individual.

Some best practice health monitoring is not compulsory and is offered to provide reassurance.

Some health surveillance is required prior to starting (as a baseline recording) and upon leaving (to confirm health status) specific roles within the University.

2 - Key legislative requirements

  • The Health and Safety at Work (etc) Act 1974
  • Provision and Use of Work Equipment Regulations 199
  • The Management of Health and Safety at Work Regulations 1999
  • Control of Substances Hazardous to Health 2002
  • Control of Vibration at Work Regulations 2005
  • The Control of Noise at Work Regulations 2005

3 - Duty holders

3.1 Deans of Schools/Heads of Professional Services

Deans of Schools/Heads of Professional Services shall:

  • Ensure that competent, suitable and sufficient numbers of staff are appointment and trained as risk assessors within their area of responsibility.
  • Ensure staff undertake appropriate risk assessments and implement appropriate control measures for all work which poses a risk to the health of workers
  • Support the nominated person(s) in implementing measures to comply with health surveillance regulations.
  • Ensure all managers and employees within the department discharge their responsibilities in accordance with this policy.
  • Seek confirmation and review from School/Service staff that arrangements are still effective

3.2 School/Department Safety Officers or Responsible Person (RP)

SSO’s/DSO’s/RP shall monitor the effectiveness of any control measures and make recommendations to the Dean of School/Head of Service as necessary. In particular:

  • Monitor that all risk assessments and health surveillance are in accordance with the policy and ensure the asset list is kept up to date.
  • Assist in training of all staff, students and visitors
  • Audit risk assessments documentation to verify that suitable and sufficient assessment are in place and up to date.
  • Suitable personal protective equipment (PPE) is provided where appropriate and is maintained to a good order. Reusable items are regularly examined for faults, damage, wear and tear.
  • Verify that plant, equipment and engineering controls are maintained in accordance with the agreed maintenance schedule.
  • Liaise with occupational health service to arrange health surveillance if its suspected that staff are at risk.

3.3 Line Managers/Academic Supervisors

Staff who are responsible for managing the activities carried out by students and staff, have a duty to ensure the health and safety of the students/staff they supervise.

Line managers are responsible for the health and safety of the staff/students they manage and others who may be affected by their work.

Line Managers/Academic Supervisors will ensure:

  • Ensure appropriate risk assessments are carried out and reviewed as required- Whoever undertakes the risk assessment for the work is responsible for identifying the
  • need for health surveillance
  • Ensure employees are suitably trained in all aspects of the safe operation of equipment
  • Identify all workers who may require health surveillance and inform Occupational Health
  • Ensure workers receive appropriate health surveillance from Occupational Health
  • Ensure workers comply with guidance given by Occupational Health

3.4 Individual

Individuals identified as requiring health surveillance must:

  • Attend any Occupational Health appointments required by risk assessment
  • Follow risk assessment and health surveillance instructions
  • Not put the health of themselves or others at risk by any of their actions.

3.5 Occupational Health

The University Occupational Health provider will:

  • Advise on any guidance and provide advice on health surveillance for specific risks
  • Undertake and arrange appropriate health surveillance
  • If a concern is identified, Occupational Health will advise on any remedial action to be taken
  • Workplace recommendations and adjustments may be provided
  • Support any health surveillance training offered by the University
  • Provide statistics relating to health surveillance

4 - Common examples of health surveillance/monitoring

When a risk assessment identifies potential risks to the health of the worker, health surveillance/monitoring is required. Examples of which may include:

  • Use of specific chemicals (eg Cadmium)
  • Working with biological agents
  • Working with respiratory sensitisers
  • Fumes, dusts, other substances hazardous to health
  • Work causing exposure to excessive noise or vibration
  • Working at heights
  • Working in confined spaces
  • Ionising radiation
  • Exposure to asbestos
  • Pregnant workers
  • University vehicle drivers
  • Night work

Schools/services should first complete a risk assessment which would identify any potential risks to health. The hierarchy of control should then be employed.

 risk assessment hierarchy of control chart


Please be aware that it is the responsibility of the manager to notify Occupational Health of anyone who requires health surveillance.

5 - Health surveillance guidance

Noise - Compulsory

Type of work involved

Statutory health surveillance is required for workers regularly exposed to noise identified as being 80-85dBA 

Work which is identified as exposing the user to levels above 85dBA over a working day

Surveilance to be carried out

Specific audiometry questionnaire

Hearing tests:

  • New starter
  • Annually (for 2 years)

3 yrly as recommended by HSE

Skin sensitisers/irritants - Compulsory

Type of work involved

Potential for exposure to skin sensitisers which have been identified by COSHH assessment or data sheet. 

Workers exposed to regular episodes of ‘wet work’ which is prolonged submersion in water or frequent requirement for hand washing.

Surveilance to be carried out

Baseline questionnaire and visual check on employment, then annually.

Respiratory sensitisers - Compulsory

Type of work involved

Potential for exposure to respiratory sensitisers which have been identified by COSHH assessment or data sheet.

Surveilance to be carried out

Baseline questionnaire and spirometry test on employment, then annually.

Vibration - Compulsory

Type of work involved

Statutory health surveillance for workers exposed to hand or arm vibration- Required if daily average exposure (EAV) exceeds 2.5m/s2 A.

Surveilance to be carried out

Baseline questionnaire then annual questionnaire with formal assessment if indicated due to symptoms.

Asbestos - Compulsory

Type of work involved

Statutory assessments required for licensed asbestos work, best practice to include non-licenced work.

Surveilance to be carried out

Baseline assessment then 3 yearly for non-licensed work or 2 yearly for licenced work.

Driving - Compulsory

Type of work involved

Fork lift truck or group 2 licence

Best practice for driving university vehicles

Surveilance to be carried out

Questionnaire - Utilising the fitness to drive standards issued by DVLA provides the basis for assessment.

Assessment to include:

  • Vision assessment
  • Hearing
  • Mobility and flexion

FLT frequency:

  • Baseline on commencement
  • Every 5 years until age 45
  • Annually after 45 

University vehicles assessment frequency - baseline on commencement then 3 yearly.

Biological agents

Type of work involved


Surveilance to be carried out

Ensure appropriate vaccination of offered where possible to individuals working with biological agents.

Working at heights

Type of work involved

School/service risk assessment.

Surveilance to be carried out

Questionnaire and safety critical medical assessment taken on commencement and 3 yearly thereafter.

Night work

Type of work involved

Workers who regularly undertake a minimum of 3hrs of night work must be offered a health assessment.

Surveilance to be carried out

Annual health questionnaire followed up with referral to Occupational Health if concerns are identified.

Employees do not have to undertake a health assessment.

DSE assessment

Type of work involved

All DSE users should be offered an online DSE assessment on commencement and annually thereafter.

Surveilance to be carried out

Annual assessment in the first instance – referral to local DSE assessors for more specific input but if concerns persist – referral to Occupational Health.


If an employees health changes it is their responsibility to inform their line manager and health surveillance maybe required to be undertaken at that point. The line manager would then make a specific referral to he Occupational Health department outlining this requirement.


6 - Records Keeping of Health Surveillance

All health surveillance records completed by the Occupational Health department are confidential. Specific details of an individuals medical record can only be given to the manager with written informed consent by the individual.

Records relating to health surveillance will be kept for at least the minimum time required by relevant and current legislation including the General Data Protection Act (GDPR).