Health surveillance professional input and follow-up record
- Version
- v1
- Updated
- 7 October 2026
- Reviewed
- 7 October 2026
- Audience
- Primary and secondary schools in England, including maintained schools and academies, excluding independent schools. Complete this record where the school establishes or operates a health surveillance scheme.
- Jurisdiction
- england
Blank fields · read-only preview
Use this record where the school establishes or operates a health surveillance scheme. Record professional input, surveillance feedback, worker concerns, preventive actions, and any training or educational reinforcement arising from the scheme.
School and record details
School name
RequiredEnter the name of the school covered by this record.
School name
Record completed by
RequiredEnter the name and role of the person completing this record.
Name and role
Date of record
RequiredEnter the date on which this record is completed.
- Day
- Month
- Year
Current health surveillance scheme status
RequiredSelect the status that applies to this record.
Choose one
- Being established
- Operating
- Under review
- Temporarily suspended
Competent occupational health professional
Professional's name
RequiredEnter the name of the occupational health professional who provided, or is expected to provide, input.
Full name
Professional's organisation or service
RequiredEnter the employing organisation, occupational health provider, or professional service.
Organisation or service
Professional's role and qualifications
RequiredRecord the role, relevant qualifications, registration details where applicable, and experience relied on for this input.
Role, qualifications, registration and relevant experience
Basis for considering the professional competent for this input
RequiredDescribe the evidence or information used by the school to establish the professional's competence for the health surveillance advice provided.
Describe the competence basis
Date of professional input
RequiredEnter the date of the relevant consultation, review, or advice.
- Day
- Month
- Year
Input into setting up or reviewing the scheme
Areas covered by the professional's input
RequiredSelect all areas covered. Do not select areas that were not discussed or reviewed.
Choose all that apply
- Whether health surveillance is needed
- Workers or groups in scope
- Relevant work-related health effects or exposures
- Surveillance arrangements and frequency
- Referral or follow-up arrangements
- Review arrangements
- Other
If other, please specify
Summary of professional input
RequiredSummarise the advice given and how it informed the scheme's design or review.
Summary of advice and resulting decisions
Limitations, unresolved questions, or further advice needed
RequiredRecord any matters that remain unresolved or require further professional input. Enter “None identified” if no such matters were identified.
Unresolved matters or further advice needed
Surveillance feedback and worker concerns
Type of feedback or concern recorded
RequiredSelect all that apply to the feedback available for this review. Do not include identifiable health information unless it is necessary and appropriately managed elsewhere.
Choose all that apply
- Feedback indicating further preventive action may be needed
- Concern raised by a worker about work-related health effects
- Training or education reinforcement opportunity
- No relevant feedback or concern identified
- Other
If other, please specify
Summary of surveillance feedback
Record the non-identifiable summary of feedback relevant to preventive action or protection of workers.
Non-identifiable summary of feedback
Worker-raised concerns and response
Record the concern, how it was considered, and any response or referral. Keep personal health information in the appropriate confidential record rather than this form.
Concern and response
Preventive actions and reinforcement
Action outcome
RequiredSelect the outcome of reviewing the feedback.
Choose all that apply
- Preventive action required
- Training or educational reinforcement required
- Further occupational health professional review required
- No further action identified at this review
- Other
If other, please specify
Preventive actions
RequiredDescribe actions to prevent further harm or protect workers, including the responsible person and target date where an action is required. Enter “Not applicable” if no preventive action is required.
Action, responsible person and target date
Training or educational reinforcement
RequiredDescribe any training, communication, instruction, or educational reinforcement arising from the scheme. Enter “Not applicable” if none is required.
Training or educational reinforcement
Date for follow-up review
Enter the planned date to review outstanding actions or reinforcement. Leave this blank only where no follow-up is required.
- Day
- Month
- Year
Has this record been reviewed by the responsible school representative?
Tick only when the recorded information and any required follow-up have been reviewed.
- Tick when complete
Additional notes
Record any other relevant non-identifiable information.
Additional notes