Occupational Safety and Health Regulation 5.23 & 5.24 - where no specific health surveillance form is available, Appointed Medical Practitioners should use this form when supervising health surveillance on workers who are at risk of suffering an identifiable disease or health effect due to exposure at work and return the completed form to Occupational Physician, WorkSafe, Locked Bag 14, Cloisters Square PERTH  WA  6850