Silica dust register

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Silica dust exposure

Have you been exposed to silica dust at work?

Yes No

Brief description of how you were exposed to silica dust:

Employer (name and address)
Site location where exposure occured (address)

Dates of employment

Start:

End:

Brief description of how you were exposed to silica dust

Please use +/- buttons to add or remove additional employer details relating to your exposure

In addition to silica dust, have you experienced periods of time with high exposure to dust in general?

Yes No

If yes, please give details:

Have you ever been told that you may be suffering from an illness caused by silica dust?

Yes No

If yes, what condition are you suffering from?:

When were you diagnosed?

Does your employer use water suppression?

Yes No

Does your employer provide face fitting RPE?

Yes No

Have you ever applied to the DWP for industrial injuries benefit for silica or dust related disease?

Yes No

If yes, when did you claim?

Have you ever previously obtained legal advice in connection with a compensation claim for a silica dust related illness?

Yes No

Please give the name and address of the solicitors:

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Unite Legal Services Silica Dust Questionnaire

Silica dust exposure

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