- Governing Policy
- Preventive Approaches are a Priority
- When Should Health Monitoring be Triggered?
- Shared Responsibilities for Health and Air Monitoring
- Health and Air Monitoring Procedures for Hazardous Chemicals, Gas, Asbestos, Lead and Communicable Diseases
7.1 Hazardous Chemicals
7.2 Gas Sources
7.5 Communicable Diseases Exposures
- Engaging Relevant Staff about Health Monitoring Requirements
- Engaging Students about Health Monitoring Requirements
- Mandatory Notifications to WHS Regulators
- Health and Air Monitoring Records
- Revisions made to this Procedure
- Further Assistance
This procedure is governed by the Work Health and Safety, and Wellbeing (WHS&W) Policy.
This procedure applies to all staff, staff representatives, students, visitors, volunteers and contractors, and the working and learning activities which the University manages or influences.
The legal requirements that are associated with noise exposures and Scheduled Substances have been excluded from the scope of this procedure as the University disposed of its Scheduled Substances in 2019. However, these health monitoring requirements will be triggered if the University acquires Scheduled Substances and issues hearing protection to staff members.
This procedure supports the University to monitor its Work Health and Safety Management System (WHSMS or framework) and to verify that treatments (controls) to manage specific WHS risks are effective. The Health and Air Monitoring Procedure also supports the University to comply with its legal obligations to initiate health and air monitoring and keep its staff safe.
Health monitoring should never be used as an alternative to the identification and management of WHS risks. This preventative approach is reinforced within this procedure and the WHS Risk Management Procedure. These procedures serve to communicate the prevention of hazard exposures should be an overriding priority and that treatments (controls) to manage these threats should be documented within WHS risk assessments and associated treatment plans. Health and air monitoring requirements should also be included within the scope of the treatments that are selected to manage hazardous chemicals, gas, asbestos, lead and communicable diseases.
Health monitoring will be conducted whenever health risks are identified and a medical practitioner, who has experience in health monitoring, has recommended a scientific and proven way to measure the effects of a health exposure.
ACU also complies with its legal obligations to conduct health and air monitoring whenever anyone may have been/will be exposed to known physical hazards, hazardous substances or a communicable disease.
The initial monitoring activities, which may be undertaken to confirm whether treatments are effective or determine any potential exposures, will be centrally funded from the relevant organisational WHS overhead.
Staff, students and contractors participate in health monitoring to support ACU to maintain its safe campuses and comply with its health monitoring duties and policy commitments. Staff and students will be informed by their Nominated Supervisors and other relevant staff about the possible health effects from exposure to hazards and the need to initiate health and air monitoring whenever this monitoring is conducted.
Table 1: An overview of health and air monitoring responsibilities
Roles and Responsibilities
Staff, staff representatives and students
Participate in health monitoring whenever it is required and engage with any University consultations about health and air monitoring which may impact upon them or University processes. Staff also collaborate with Nominated Supervisors and others to develop and apply treatments that are informed by the results of monitoring.
Nominated Supervisors and Managers
These staff may coordinate health monitoring activities and engage with staff, students, contractors and others about the need for health and air monitoring. They will also strengthen treatments whenever monitoring reports and expose deficiencies in the ways that specific risks are treated. These staff also collaborate with relevant executives, Incident Leads and health authorities to manage any communicable disease outbreaks.
Engage with the University’s two-way consultations about health and safety issues and comply with legal obligations to manage significant risks, conduct health and air monitoring, and collaborate with the University to comply with legal requirements which are associated with regulator notifications.
Properties and Facilities
Engage with contractors about hazards and WHS risks, and ensure that contractors comply with their legal obligations to comply with health and air monitoring requirements. They also ensure that WHS risk assessments are conducted to identify hazardous activities, such as lead risk work, and ensure that significant WHS risks are managed.
Ensure that significant risks are managed and the University complies with its legal obligations to initiate health and air monitoring and develop more robust treatments whenever adverse results are received. These staff also engage with relevant staff, staff representatives, students, contractors and others about health and air monitoring.
Employment Relations and Safety staff
Collaborate with other work areas to ensure that the University complies with its obligations to conduct health and air monitoring and retain records of monitoring. These staff also influence work areas to ensure that health and air monitoring is initiated to confirm that existing treatments, to manage specific WHS risks, are effective.
7. Health and Air Monitoring Procedures for Hazardous Chemicals, Gas, Asbestos, Lead and Communicable Diseases
This section outlines the requirements for health and air monitoring that is associated with hazardous chemicals, gas, asbestos, lead and communicable diseases.
7.1.1 Air Monitoring Can Trigger Health Monitoring
Relevant Nominated Supervisors and Managers, in collaboration with Facilities Management staff, should coordinate air monitoring activities after reviewing whether they are required. This monitoring should be conducted by an occupational hygienist, whenever:
- It is not certain whether the exposure standard for airborne contaminants has been exceeded; and
- A health risk has been identified during an incident investigation or the development of a WHS risk assessment and associated treatment (control) plan.
This air monitoring will confirm whether any one has been exposed to a substance or a mixture within an airborne concentration, which exceeds the Workforce Exposure Standards for Airborne Contaminants.
This monitoring should measure the amount of a hazardous chemical or substance in the atmosphere within a working and learning area. The air monitoring will help determine the effectiveness of existing treatments (controls), the extent of any exposure (s) and will inform the assessment of WHS risks.
188.8.131.52 Annual Formaldehyde Testing
The Manager Scientific Services should coordinate annual air testing of formaldehyde levels within anatomy laboratories. This testing is conducted using a colorimetric test.
If the levels of formaldehyde exceed the Exposure Standards, another test will be conducted. If the results from the second test are consistent with the initial test, a review of the ventilation system will be coordinated by the local State Facilities Manager or Nominee.
7.1.2 Health Monitoring
Health monitoring requirements should be documented within WHS risk assessments, and associated treatment plans should be developed by technical and other staff.
Health monitoring should be provided to staff, students and others if it is determined that exposure to a hazardous substance could have exceeded the exposure standard. However, whenever risks are being treated in compliance with established practices for managing hazardous substances, including the recommendations of Safety Data Sheets (SDS), health monitoring would normally not be required.
The chemicals that should be included with the scope of health monitoring include those substances that are known or presumed to be carcinogenic, mutagenic, toxic to human reproduction, respiratory or skin sensitizers.
Health monitoring requirements may be triggered by an incident investigation (documented within a riskware Action Plan) or the results of air monitoring. Health monitoring should also be conducted whenever staff and students are using hazardous substances and there is a significant risk that exposure levels have exceeded the Standard and there are valid techniques to determine these exposures (recommended by a medical practitioner who has relevant experience in health monitoring).
If a spill of a known hazardous chemical occurs or there is a loss of containment, staff and students will also be offered health assessments, by the University or a relevant insurer, if ACU has a reasonable concern about an exposure, or the wellbeing of another person(s), or they have symptoms that are consistent with chemical exposures.
7.2.1 Gas Monitoring
Nominated Supervisors and Managers, in consultation with Human Resources WHS and Facilities Management staff, should undertake gas monitoring if there is a risk of a hazardous atmosphere, which may have resulted from an asphyxiant leak (resulting in oxygen falling to unsafe levels). A leak may also increase a risk of a fire and should be reported to the ACU National Security Centre on 8000 (internal phone) or 1300 729 452 as the Incident Convenor (critical incident management) should be notified.
This monitoring should also be initiated if:
- The concentration of flammable gas (or vapour, mist or fume) exceeds 5% of the Lower Explosive Limit (LEL) for that gas;
- Combustible dust is present in a form or quantity that could ignite; or
- A strong smell of toxic gas (or identified by other means) suggests that gas could be have escaped and may exceed the exposure standard.
7.3.1 Identifying and Resolving Hazards
WHS risk assessments should be conducted by Properties and Facilities staff or relevant contract Project Managers to help determine whether any Asbestos Containing Materials (ACM) are present and could be disturbed by the demolition or refurbishment of any structures or plant constructed prior to 2004. These assessments should be informed by the Hazardous Materials Register for the site and any new identification processes.
If Properties and Facilities staff or Contract Project Managers determine that ACM is likely to be disturbed, a licensed contractor will be used to remove these materials, prior to the commencement of refurbishment work, and the local HAZMAT Register should be updated by the Directorate.
Properties and Facilities staff will ensure the relevant WHS regulator is notified, by the licensed asbestos removalist, at least five days prior to the removal of the ACM.
7.3.2 Air Monitoring
Air monitoring should be conducted for any ACM removal works in the following circumstances:
- It is likely the levels of exposure are higher than the Asbestos Exposure Standard;
- It cannot be determined whether the standard will be exceeded; and
- An independent licensed asbestos assessor determines it is required.
Air monitoring should also be conducted in the event of an uncontrolled disturbance or release of asbestos. In these circumstances, the relevant WHS regulator should be notified within 24 hours of any removal works and a notifiable incident should be urgently reported.
Properties and Facilities staff should ensure that an independent licensed asbestos assessor immediately conducts this monitoring within the asbestos removal area unless glove bags are used. The monitoring will continue throughout the asbestos removal work and until the area has been decontaminated, and prior to any enclosures being dismantled.
A Clearance Certificate should be obtained prior to the commencement of other demolition or refurbishment work, or the reoccupation of the relevant working and learning area.
7.3.2 Asbestos Health Monitoring
Health monitoring will be offered to staff, students, contractors and others by relevant contractors, contract Project Managers or ACU staff if there is a risk that they were exposed to asbestos fibres at levels which exceeded the Asbestos Exposure Standard.
Properties and Facilities staff will confirm that health monitoring, via medical examinations, is being provided to contractors who are carrying out licenced asbestos removal work and have been exposed to ACM risks.
Lead can be found in high levels in buildings built prior to the 1980s in materials such as flashing, sheet lead, PVC products, lead solder, plumber fittings and paint that is flaking.
7.4.2 Assessing WHS Risks and the Need for Monitoring
A WHS risk assessment should be conducted by relevant Supervisors, within Properties and Facilities, or contract Project Managers for maintenance or construction work that involves a lead process. The scope of this assessment should include a determination about whether the work could be classified as a lead risk work that will result in potential lead exposures.
If these exposure levels cannot be identified during this assessment the job should be classified as a lead risk work and effective treatments (controls) should be developed to manage this risk.
Work, involving the following scenarios, may be classified as a lead risk work:
- Dry machine grinding, discing, buffing or cutting by power tools alloys containing more than 5% by work of lead metal;
- Machine sanding or buffing surfaces coated with paint (more than 1% of dry weight of lead);
- Welding, cutting or cleaning the surface of metal coated with lead or paint (containing more than 1% of dry weight of lead metal; and
- Other scenarios that are specified in WHS regulations.
Whenever an activity is identified as lead risk work, relevant Properties and Facilities staff should ensure either the scope of the work is reduced to limit the threat of lead exposures or notify the Director of Properties and Facilities and collaborate with relevant staff or contractors to ensure the relevant State WHS regulator is notified, within seven days, about the job being lead risk work, which will trigger monitoring requirements.
7.4.3 Health Monitoring: Planned Activities Involving Staff and Contractors
Any staff member or contractor conducting lead risk work will be required to participate in health monitoring, conducted by a suitably qualified practitioner, both prior to the commencement of this work and once again in a month’s time.
Ongoing biological monitoring of staff or contractors, who are conducting lead risk work, should be also be initiated and Properties and Facilities staff should confirm that this monitoring is occurring.
7.4.4 Removing People from Harm
Contractors or staff should be removed from harm and the ACU National Security Centre (refer to the Critical Incident Management Policy for more information) should be contacted, on 1300 729 452 or 8888 (internal phone), if health and/or air monitoring reports show that:
- The airborne concentration of lead dust, lead mist or lead fumes are at levels that exceed 0·15 milligrams per cubic metre, (calculated as a time weighted average of the atmospheric concentration of lead over an 8-hour working day and a 40-hour working week); and
- Biological monitoring reveals the threshold of blood lead levels has been reached.
In the event that a medical practitioner recommends to the University that someone should be removed from harm, an Incident will be triggered within ACU, and the relevant Incident Convenor will assess – in collaboration with relevant staff - whether other people are likely to be impacted and determine whether other people should be removed from harm.
Properties and Facilities staff should also:
- Reassure the Incident Convenor that the area is safe;
- Collaborate with contractors and Human Resources staff to ensure the relevant state WHS regulator is immediately notified; and
- The University should provide two medical examinations (the first one immediately and the second within 30 days), in collaboration with any relevant workers’ compensation insurers, to anyone that may have been exposed. If it is determined that blood lead exceeds lead threshold levels, ongoing tests should be scheduled according to the recommendations of the medical practitioner that has experience in health monitoring.
Human Resources staff will also collaborate with relevant Properties and Facilities staff and the Incident Convenor to ensure the relevant WHS regulator is provided with a copy of the health monitoring report if relevant blood lead levels have been reached or exceeded, or the tests results indicate that a person has contracted a disease, injury or illness which resulted from a working activity.
Blood lead level thresholds:
- 2⋅41 µmol/L—for females not of reproductive capacity and males;
- 0⋅97 µmol/L—for females of reproductive capacity; and
- 0⋅72 µmol/L—for females who are pregnant or breast feeding.
7.5.1 Assess the need for health monitoring
Whenever someone has been diagnosed with a communicable disease, the following steps should be taken to assess the need for health monitoring and reduce any additional exposure risks:
Determine: Whether the relevant State health authority has been notified about the diagnosis by a relevant practitioner or hospital?
Log a report of the incident within riskware
Relevant Executive or Nominee
Call the ACU National Security Centre on 8888 or 1300 729 452 who will ensure that the relevant Incident Convenor (IC) is notified. The Incident Convenor will notify the Incident Lead.
Complete the riskware Action Plan for the incident.
Relevant Executive or Nominee
Determine who could have been exposed or is at risk of exposure and reference the relevant materials about the disease, published by relevant health authorities.
Relevant Executive or Nominee
Consult with the relevant health authority. Is health screening required (staff, students and other exposed people)?
Relevant Executive or Nominee
Email or communicate with anyone that was potentially exposed to the communicable disease and prompt these people to visit their practitioner if they are experiencing symptoms which could indicate that exposure has occurred.
Relevant Executive or Nominee
Incident/Critical Incident Lead will collaborate with Facilities Management to decontaminate/disinfect relevant working and learning areas (if required)
Relevant State Facilities Manager or Nominee
Develop and distribute communications about the health screening, to be distributed to anyone that has a high risk of exposure
Relevant Executive or Nominee
Timeline determined by relevant health authority
Coordinate health screening in collaboration with the relevant State health authority
Consult with Human Resources WHS staff and Health Authorities about managing the risks which are associated with anyone that has been diagnosed with a communicable disease.
Relevant Executive or Nominee
Relevant Human Resources WHS staff should be consulted about health monitoring reports and the reports should be provided to the impacted person(s) as soon as possible.
If an adverse health monitoring result is received, which relates to an exposure within the University, actions should be taken to minimise any further risks to the health and safety of the person, and the Employee Assistance Program (EAP) should be offered to any impacted staff members. Human Resources WHS staff will also discuss workers compensation options with any impacted staff.
Relevant student supervisors or Laboratory Managers should inform their Nominated Supervisor, relevant Human Resources WHS Staff of an identified potential need to provide health monitoring to a student(s).
Whenever health monitoring is offered to a student, the relevant Executive or delegate shall meet with the student (and their guardian if the student is under 18 years of age) and advise them of the importance of undertaking a program of health monitoring which will be coordinated by ACU.
In the event that an adverse health monitoring report is received: student counselling services will be offered to any affected student(s).
Human Resources WHS staff will also contact the relevant WHS regulator or confirm with Properties and Facilities staff that the regulator has been provided with a relevant health monitoring report, whenever:
- Advice or test results that indicate the person tested may have contacted a disease, illness or injury due to a working activity that triggered the health monitoring; and
- Any recommendation received about taking remedial measures, including any recommendations about whether a staff member can continue to continue to perform their existing duties.
11.1 Air Monitoring Records
Air monitoring records should be uploaded to the HPE Content Manager (refer to WHSMS Records and Document Management Procedure) by relevant Facilities Management staff to ensure that they are accessible to the relevant organisational unit who requested the testing.
Health monitoring records for visitors and volunteers should also be uploaded to the HPE Content Manager by the relevant organisational unit. Refer to the WHSMS Records and Document Management Procedure for the naming convention and recommended file paths.
11.2 Staff Health Monitoring Reports
It is essential that health monitoring reports and records are accurately maintained for at least 30 years and asbestos records should be held for 40 years.
Whenever health monitoring has been undertaken for staff, the relevant Nominated Supervisor will obtain a health monitoring report from the registered medical practitioner who carried out the health monitoring. The relevant staff member will be given access to the report and Nominated Supervisors will discuss the report and any actions taken to remove the staff member from harm or remove/mitigate the hazard from the workplace.
The relevant Nominated Supervisor shall ensure that a copy of the health monitoring report and any other relevant records are submitted to Service Central.
Health monitoring reports and any test results must be kept as a confidential record, within the relevant employment/staff record, and must not be disclosed to another person without the staff members’ written consent (which should also be attached to a relevant staff record), except when these records will be disclosed to an authority.
11.3 Student Records
Health monitoring reports for students will be maintained, confidentially, for a period of least 30 years (and asbestos records that must be retained for 40 years) and will be placed on the Banner Document Management System by Student Administration staff.
Major, Minor or Editorial
The University may make changes to this procedure from time to time to improve its effectiveness. If any staff member wishes to make any comments about this procedure, they should forward their suggestions to Human Resources.
Any staff member who requires assistance in understanding this procedure should first consult their Nominated Supervisor or Manager who is responsible for applying the University’s WHSMS within their work area. Should further information or advice be required staff should visit Service Central.
- WHSMS Health and AIr Monitoring Procedure (Policy, PDF File, 162.2 KB)
|Policy applies to||
All Staff And Students
|Policy Status||New Policy|
|Approval Authority||Vice-Chancellor And President|
|Governing Authority||Chief Operating Officer|
|Responsible Officer||Director, Human Resources|
|Date of Last Revision||20/01/2020|
|Effective Date of Last Revision||20/01/2020|
* Unless otherwise indicated, this policy will still apply beyond the review date.
Related Policies, Procedures, Guidelines and Local Protocols
- Work Health and Safety Regulations, 2011 (ACT, NSW, QLD)
- Occupational Health and Safety Regulations, 2007, 2017 (VIC)
- Guide | Asbestos, Hazardous Chemicals Requiring Health Monitoring, Safe Work Australia
- Workplace Exposure Standards for Airborne Contaminants, Safe Work Australia
- Work Health and Safety, and Wellbeing (WHS&W) Policy
- WHS Risk Management Procedure
- WHS Risk Assessment Form
- WHS Risk Assessment Form for Practical Activities
- Critical Incident Management Policy
- Asbestos Standard
- ACU Chemical Management Procedure
- Laboratory Safety Guidelines
- Model Code of Practice Managing noise and preventing hearing loss at work, Safe Work Australia
- Health Monitoring for Exposure to Hazardous Chemicals (Guide for Medical Practitioners), Safe Work Australia
Page last updated: 2020-02-19
Short url: https://policies.acu.edu.au/2340330