School Health Surveillance Feedback and Preventive-Action Record template

CalmComplianceForm template

School Health Surveillance Feedback and Preventive-Action Record

Version: v1
Updated: 1 October 2026

Audience: Primary and secondary schools in England, including maintained schools and academies, that operate a health surveillance scheme and need to document its outputs and resulting actions.
Jurisdiction: england

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Applicability and confidentiality

Complete this record only where the school operates a health surveillance scheme and the scheme has produced feedback, worker-raised concerns or recommendations for further preventive action. Record only the information needed to manage actions. Do not enter diagnoses, detailed clinical information or other confidential health information in this form; retain such information within the appropriate confidential occupational-health arrangements.

Does this record concern an operating health surveillance scheme?

Required

Select Yes only when the school has an applicable health surveillance scheme and this record relates to its outputs or resulting actions.

Choose one

Record details

School name

Required

Enter the name of the maintained school or academy.

Written response

School reference or establishment number

Required

Use the school's internal reference or establishment number.

Written response

Person completing the record

Required

Enter the name and role of the person responsible for recording the outcome.

Written response

Date of surveillance output or feedback

Required

Enter the date on which the relevant surveillance output, concern or recommendation was received.

Day
Month
Year

Work activity or exposure covered by the scheme

Required

For example, cleaning chemicals, laboratory work, maintenance activities or other work-related exposure. Do not include a person's name.

Written response

Surveillance output and concerns

What did the surveillance scheme produce?

Required

Select all applicable outputs. Summarise only non-confidential information in the fields below.

Choose all that apply

Feedback about further preventive action
Worker-raised concern about a work-related health effect
Occupational-health recommendation
Recommendation to review or change controls
Need to reinforce training or education
Recommendation for referral through occupational-health arrangements
No further preventive action identified
Other

If other, please specify

Worker group or role affected

Required

Describe the relevant worker group or role without naming individuals.

Written response

Summary of worker-raised concerns

Required

Summarise concerns about how work may affect health. Do not include names, diagnoses, test results or detailed clinical information. Enter “None reported” where no worker concern was raised.

Written response

Summary of occupational-health feedback or recommendations

Required

Record the action-relevant recommendation, not confidential clinical details. Enter “None received” where no occupational-health feedback was provided.

Written response

Preventive actions and referrals

Are further preventive actions required?

Required

Select the current status based on the surveillance output and applicable occupational-health arrangements.

Choose one

Yes, actions are required
Actions are already in progress
No further actions are currently required
Further review is required before deciding

Preventive actions agreed or proposed

Required

Describe actions such as reviewing work methods, improving controls, providing information or arranging occupational-health follow-up. If no action is required, explain why.

Written response

Referral or occupational-health follow-up status

Required

Do not record clinical details. Record only the administrative status needed to track the action.

Choose one

Not applicable
Required but not yet arranged
Arranged
Completed and action-relevant feedback received
Awaiting action-relevant feedback

Changes to existing controls

Required

Describe any changes made or proposed to controls, work arrangements, equipment, procedures or supervision. Enter “No changes” where appropriate.

Written response

Training and education

What training or educational reinforcement is needed?

Required

Select all applicable actions. The selection should reflect the surveillance outcome.

Choose all that apply

None identified
Refresher training
Team briefing or toolbox talk
Updated written guidance
Supervisor or manager briefing
Individual work-practice support through appropriate arrangements
Other

If other, please specify

Training or education details

Required

Describe the subject, audience and intended outcome. Do not identify a worker or include confidential health information. Enter “Not applicable” where no reinforcement is needed.

Written response

Action owner

Required

Enter the role or named person responsible for coordinating the recorded actions.

Written response

Target completion date

Required

Enter the date by which the preventive actions, control changes or training actions should be completed. Use the date agreed by the school.

Day
Month
Year

Have the recorded actions been completed?

Required

Select the current status. Update this record when outstanding actions are completed or circumstances change.

Choose one

Completed
Partially completed
Not started
No action required
Closed under the school's occupational-health arrangements

Next review date

Required

Enter the date for checking outstanding actions, changed controls or any need for further follow-up.

Day
Month
Year

Additional action-tracking notes

Record relevant decisions, dependencies or follow-up arrangements. Do not include confidential health information.

Written response

School Health Surveillance Feedback and Preventive-Action Record